Jones & Bartlett Learning Medicine Blog

    Perioperative Statin Therapy Reduces Perioperative Cardiac Events and Hospital Length of Stay

    Posted by Joseph Esherick on Aug 28, 2012 9:47:52 AM

    Perioperative statin therapy has long been felt to confer cardiac protection during both cardiac surgery and major noncardiac surgery.  Until recently the data have been scarce to definitively make claims in support of this belief.  In 2004, Durazzo et al. conducted the first randomized trial examining the use of Perioperative statins in major noncardiac surgery.  They compared the use of atorvastatin 20 mg daily compared against placebo initiated 2 weeks prior to elective major vascular surgery and continued for 45 days post-operatively.  The investigators found that statins were associated with a 70% relative risk reduction of the combined end-point of death, nonfatal MI, unstable angina, or stroke. [1] Prior to this in 1999, Christenson had demonstrated cardioprotective effects of statins during coronary artery bypass grafting surgery. [2]

    Statins are thought to be beneficial for a myriad reasons:

    • They lower lipids and have additional pleiotropic effects.
    • The cardioprotective effects of statins during the perioperative period is more likely related to their pleiotropic effects than their lipid-lowering effects.
    • Statins inhibit the action of HMG-CoA Reductase which is the rate-limiting step in cholesterol synthesis, but effective lipid lowering takes months.
    • Perioperative studies have demonstrated that statins confer a cardioprotective benefit when started even 1-2 weeks in advance of major surgery.
    • These pleiotropic effects of statins include suppression of endothelial nitric oxide which promotes coronary vasodilation.
    • Statins also reduce lipopolysaccharide-induced tissue factor release, decrease plasminogen activator inhibitor levels, and increase tissue plasminogen activator; the combination of which reduces coronary thrombosis.
    • Statins also have anti-inflammatory properties which may provide more plaque stability. [3]
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    Topics: Stroke, cardiac surgery, cholesterol, Dr. Joseph Esherick, Authors, MI, atorvastatin, atrial fibrillation, beta-blockers, bypass grafting surgery, Cardiology, cardioprotective, coronary artery, Hospital Medicine Blog, lipids, myonecrosis, statin therapy, unstable angina

    Beta-Blockers: Beneficial For Older Patients with Chronic Obstructive Pulmonary Disease?

    Posted by Joseph Esherick on Jan 26, 2012 10:32:42 AM

    Dr. Joseph Esherick Monthly Blog – January 2012

    When I was in medical school in the early 1990’s, one of the principles that I learned was to never prescribe beta-blockers to patients with chronic obstructive pulmonary disease (COPD).  We knew that stimulation of beta-2 receptors caused bronchodilation and therefore the belief was that beta-blockers would cause bronchospasm and lead to COPD exacerbations.  This practice was analyzed in a Cochrane review by Salpeter et al. in 2005 which concluded that, “cardioselective beta-blockers, given to patients with COPD do not produce a significant short-term reduction in airway function or in the incidence of COPD exacerbations. “[1] Another study focusing on the treatment of systemic hypertension in patients with pulmonary disease also concluded that cardioselective beta-blockers (β1-selective antagonists) were safe to use in patients with stable COPD.[2] One final review of the available evidence came to the same conclusion that, “the use of cardioselective beta-blocker therapy in patients with cardiovascular disease and comorbid COPD [appears safe].”[3]

    These previous reviews attested to the safety of beta-blocker therapy in patients with stable, mild-moderate COPD.  However, a recent study analyzed the question whether beta-blockers in patients with COPD are beneficial if there is an indication for their use?[4]

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    Topics: cardiovascular disease, Dr. Joseph Esherick, Authors, Tarascon Medical Procedures Pocketbook, Tarascon Primary Care Pocketbook, beta-blocker therapy, beta-blockers, bronchospasm, Cardiology, chronic obstructive pulmonary disease, COPD, Hospital Medicine Blog, Tarascon Hospital Medicine Pocketbook

    Pre-Procedural Statins Reduce the Incidence of Peri-procedural Cardiac Events

    Posted by admin on May 20, 2011 2:07:07 PM

    Dr. Joseph Esherick Monthly Blog - May 2011

    Initiation of statins during the acute period has been shown to be beneficial during an acute coronary syndrome and immediately following an ischemic stroke. [1,2,3] It is believed that statins, HMG-CoA reductase inhibitors, have pleiotropic properties that have anti-inflammatory effects, improve endothelial function and inhibit the body’s thrombogenic response.  The properties are in addition to the lipid lowering effects of statins.  These pleiotropic effects are felt to be the principal mechanism by which statins decrease recurrent cardiovascular and cerebrovascular events when started acutely during an acute coronary syndrome or immediately after an ischemic stroke.  Statins have also been shown in two randomized controlled trials to decrease the incidence of peri-procedural myocardial infarction if started soon before percutaneous coronary intervention or before major vascular surgery. [4,5]

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    Topics: Cardiac Events, Authors, Statins, Cardiology, cardiology, Hospital Medicine Blog

    Treatment & Management of Acute Coronary Syndrome

    Posted by admin on Apr 25, 2011 1:15:24 PM

    Dr. Joseph Esherick Monthly Blog - April 2011

    The leading cause of death in the United States is cardiovascular mortality.  Therefore, the early identification and appropriate management of acute coronary syndrome is essential for all hospital-based physicians.  The American College of Cardiology Foundation and the American Heart Association have recently updated their practice guidelines on the management of patients with unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI)1.

    This blog will focus on the primary changes in the management of non-ST-elevation acute coronary syndrome.  The Level 1 recommendations are that patients with definite UA/NSTEMI at medium to high risk should receive 325 mg of aspirin and a second antiplatelet agent on presentation.  Dual antiplatelets should be given regardless of whether an invasive or conservative strategy is chosen.  The second antiplatelet agent could be either a loading dose of clopidogrel, prasugrel, or a GP IIb/IIIa inhibitor (preferably eptifibatide or tirofiban).  The major change in the recommendations is that dual antiplatelet therapy is now routinely recommended upstream of percutaneous coronary intervention (PCI).  In patients undergoing PCI, both aspirin and a thienopyridine, clopidogrel or prasugrel, should be continued for at least 12 months.  For those treated conservatively, dual antiplatelet therapy should continue for at least 1 month and ideally for 1 year.

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    Topics: medication, American Heart Association, American college of cardiology, Cardiology, cardiology, Hospital Medicine Blog

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