Effect of prophylactic amiodarone on clinical and economic outcomes after cardiothoracic surgery: a meta-analysis

BACKGROUND: Two previous meta-analyses of amiodarone for prevention of postoperative atrial fibrillation (POAF) after cardiothoracic surgery did not evaluate total hospital cost, concluded that data on stroke are incomplete, and did not evaluate the effect of clinical heterogeneity between trials. OBJECTIVE: To conduct a meta-analysis examining amiodarone's prophylactic impact on cardiothoracic surgery POAF, length of stay (LOS), stroke, and total costs. METHODS: Three reviewers conducted a systematic literature search of MEDLINE, EMBASE, CINAHL, and the Cochrane Library (1966-SEPTEMBER 2004). Studies were included if they met the following criteria: (1) randomized controlled trial versus placebo/routine treatment, (2) coronary artery bypass graft and/or valvular surgery, (3) Jadad score > or = 3, (4) reported data on incidence of POAF or stroke, LOS, or total costs, (5) used electrocardiographic/Holter monitoring, and (6) monitored subjects for > or = 2 days. A random-effects model was utilized. Subgroup and sensitivity analyses were conducted. RESULTS: Fifteen trials were identified, including 1512 and 1429 patients in the amiodarone and control groups, respectively. Amiodarone reduced POAF (OR 0.50; 95% CI 0.42 to 0.60) and decreased stroke (n = 8 studies), LOS (n = 10), and total costs (n = 6) (OR 0.47; 95% CI 0.23 to 0.96; -0.73 days, 95% CI -0.95 to -0.51; and -dollar 1619, 95% CI -3395 to 156, respectively). Surgery type, beta-blocker use, route of administration, use of a fixed-effects model, or exclusion of unblinded/unpublished studies did not affect the overall results. No statistical heterogeneity was observed for any endpoint evaluated (p > 0.22 for all comparisons). CONCLUSIONS: Prophylactic treatment with amiodarone decreases patients' risk of POAF and stroke while reducing LOS.     

围术期应用胺碘酮预防心脏不停跳冠状动脉搭桥术后房颤的研究

目的探讨围手术期应用胺碘酮在预防非体外循环下心脏不停跳冠状动脉搭桥术后房颤中的作用。方法采用随机对照的研究方法,将2009年1月至2011年1月在我科进行非体外循环下心脏不停跳冠状动脉搭桥术的患者随机分为试验组和对照组,每组各100例。A组为试验组,术前口服胺碘酮,600mg/d(200mgtid),连续7d,之后改为200mg/d至术前,术后当天开始静脉滴注胺碘酮,负荷量为5mg/kg,之后给予维持量0.5mg.kg-1.h-1,能进食后改为200mg/d口服。B组为对照组,不给予胺碘酮治疗而仅用常规药物。观察两组患者术后房颤发生率及心率变化,同时检测试验组患者术前及术后第2天的胺碘酮血药浓度。结果两组患者的术前一般特征及手术情况相近。试验组100例患者中术后有10例(10.0%)发生房颤,对照组100例患者中有36例(36.0%)发生房颤(P=0.015)。试验组房颤时最大心室率为(126.0±20.8)次/min,房颤持续时间为1.0d,对照组房颤时最大心室率为(150.0±25.6)次/min,房颤持续时间为(3.0±1.5)d(P<0.05)。试验组术后心率慢于对照组,两组Q-T间期、术后并发症的发生及死亡率无统计学差异。试验组的住院时间为(10.6±2.8)d,对照组住院时间为(15.4±3.2)d(P<0.05)。胺碘酮血药浓度平均值术前为(797±136)ng/ml,术后第2天为(763±94)ng/ml(P>0.05)。结论胺碘酮在预防非体外循环下心脏不停跳冠状动脉搭桥术后房颤中的作用显著,能安全有效地降低术后房颤的发生率,缩短房颤持续时间,且无明显不良反应。     

Significance of Supraventricular Tachyarrhythmias After Coronary Artery Bypass Graft Surgery and Their Prevention by Low-Dose Sotalol: A Prospective Double-Blind Randomized Placebo-Controlled Study

BACKGROUND: The single most frequent complication after coronary artery bypass graft surgery is the occurrence of supraventricular tachyarrhythmias leading to a prolonged hospital stay. Although several drugs have been used to treat these arrhythmias, effective prevention was only possible with beta-blocking drugs in selected patients. It was, therefore, the aim of the present study to evaluate the significance of supraventricular tachyarrhythmias in presence of today's cardioprotective management in a broad spectrum of patients and to assess the possible preventive effect and safety of low-dose sotalol after coronary artery bypass graft surgery. METHODS AND RESULTS: In a prospective randomized double-blind placebo-controlled trial, 220 consecutive patients referred for elective coronary artery bypass graft surgery were randomized to 80 mg sotalol twice daily (n = 110) or matching placebo (n = 110) for 3 months with the first dose given 2 hours before surgery. There were no significant differences in baseline characteristics between the two groups. Low-dose sotalol reduced the rate of supraventricular arrhythmias from 43% (placebo) to 25% (sotalol, P <.01), which was atrial fibrillation in 83%, flutter in 7%, and other supraventricular arrhythmias in 10%. Only 7% of all arrhythmias were observed after day 9. Hospital stay was 11 +/- 4 days in patients with supraventricular arrhythmias versus 9 +/- 2 days (P <.001) in patients without. On the fourth postoperative day, heart rate was lower in the sotalol group (75 +/- 12 versus 86 +/- 14 beats per min; P <.0001), but QTc was not significantly prolonged (sotalol, 0.44 +/- 0.03; placebo, 0.43 +/- 0.03; P, ns). Study medication had to be discontinued due to side effects in 6.4% of sotalol and 3.6% of placebo patients (P, ns), but relevant side effects occurred only in two sotalol patients late after surgery. CONCLUSIONS: These data show that without antiarrhythmic therapy the incidence of supraventricular arrhythmias after coronary artery bypass graft surgery is high (43%) and that supraventricular arrhythmias were associated with a prolonged hospital stay (+/-2 days). Prophylactic treatment with low-dose sotalol reduced the incidence of supraventricular arrhythmias significantly (by 40%), thereby reducing overall hospital stay in treated patients. Because more than 90% of all supraventricular arrhythmic episodes occurred within 10 days after surgery and considering the small proarrhythmic effect of sotalol late after surgery, prophylactic treatment with sotalol may be recommended for the first 10 postoperative days to safely reduce supraventricular tachyarrhythmias.     

Perioperative Landiolol Administration reduces Atrial Fibrillation after Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials

Introduction

Postoperative atrial fibrillation (POAF) is one of the most common complications after cardiac surgery. Patients who develop POAF have a prolonged stay in the intensive care unit and hospital and an increased risk of postoperative stroke. Many guidelines for the management of cardiac surgery patients, therefore, recommend perioperative administration of beta-blockers to prevent and treat POAF. Landiolol is an ultra-short acting beta-blocker, and some randomized controlled trials of landiolol administration for the prevention of POAF have been conducted in Japan. This meta-analysis evaluated the effectiveness of landiolol administration for the prevention of POAF after cardiac surgery.

Methods

The Medline/PubMed and BioMed Central databases were searched for randomized controlled trials comparing cardiac surgery patients who received perioperative landiolol with a control group (saline administration, no drug administration, or other treatment). Two independent reviewers selected the studies for inclusion. Data regarding POAF and safety outcomes were extracted. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the Mantel–Haenszel method (fixed effects model).

Results

Six trials with a total of 560 patients were included in the meta-analysis. Landiolol administration significantly reduced the incidence of POAF after cardiac surgery (OR 0.26, 95% CI 0.17–0.40). The effectiveness of landiolol administration was similar in three groups: all patients who underwent coronary artery bypass grafting (CABG) (OR 0.27, 95% CI 0.17–0.43), patients who underwent CABG compared with a control group who received saline or nothing (OR 0.28, 95% CI 0.17–0.45), and all patients who underwent cardiac surgery compared with a control group who received saline or nothing (OR 0.27, 95% CI 0.17–0.42). Only two adverse events associated with landiolol administration were observed (2/302, 0.7%): hypotension in one patient and asthma in one patient.

Conclusion

Landiolol administration reduces the incidence of POAF after cardiac surgery and is well tolerated.     

The value of prophylactic antibiotics in coronary artery bypass graft surgery: A review of literature

Infections have a significant impact on increasing both the morbidity and mortality rate of patients who have undergone coronary artery bypass graft (CABG) surgery. Infection after CABG imposes a clinical and economic burden on patients and health care organizations; therefore, prevention should be on the agenda. This review will focus on the value of using prophylactic antibiotics in coronary artery bypass graft surgery (CABG). Prophylactic antibiotics like cephalosporin and vancomycin are more commonly used antibiotics and are strongly associated with reduced infection risk in patients. The results showed that using antibiotics during the perioperative period and after CABG is an effective strategy for reducing post-infection problems without compromising the patients' clinical outcomes. Diabetic patients are prone to postoperative infection after CABG, however, prophylactic antibiotics should not be the only strategy used to reduce the risk of postoperative infection in diabetic patients. Perioperative glycaemic control is essential for diabetic patients undergoing CABG. Appropriate antibiotic prophylaxis has a great impact on preventing infection after CABG but duration and selecting appropriate antibiotic is important. Standardizing the use of antibiotic prophylaxis reduces the rate of infection and unwanted bacterial resistance, which could subsequently reduce economic costs to patients and public health.     

Performance and validation of a simplified postoperative atrial fibrillation risk score

Background

Postoperative atrial fibrillation (POAF) occurs in 20–40% patients who received isolated coronary artery cardiac bypass surgery (CABG). Several POAF risk prediction models have been developed, but none of them is widely adopted in practice. Our objective was to derive and validate a simple scoring system to estimate POAF risk after isolated CABG, using easily available clinical information.

Methods

Medical records of 1,000 consecutive patients undergoing isolated CABG were reviewed. The data of first 700 patients were used for model derivation and data of the remaining 300 patients were used for model validation. Discrimination and calibration of the newly developed model were assessed.

Results

POAF incidence in both the derivation and validation cohorts was 27.3%. Age ≥65, history of hypertension, heart failure, and myocardial infarction were independently associated with POAF risk. Risk scores were calculated by summing weighting points for each independent predictor. The score ≥3 was associated with high POAF incidence (41.1% in the derivation cohort and 44.3% in the validation cohort). The positive and negative POAF predictive value was 41.1% and 78.5%, respectively, in the derivation cohort, and 44.3% and 80.8%, respectively, in the validation cohort, when the cut‐point score ≥3 was used. The Hosmer–Lemeshow goodness‐of‐fit test P‐values were 0.917 and 0.894 in the derivation cohort and validation cohort, respectively.

Conclusions

This POAF risk following isolated CABG can be predicted with simple patient characteristic during the preoperative period. Patients with high risk scores (≥3) may constitute a target population for POAF prevention and prolonged postoperative surveillance.

     

Correlates of neurocognitive function of patients after off-pump coronary artery bypass surgery.

BACKGROUND: Decreases in neurocognitive function have been reported in patients who have undergone off-pump coronary artery bypass surgery; however, few investigators have examined the correlates of the decreases. OBJECTIVES: To explore and determine the correlates of neurocognitive function at the time of discharge from the hospital in patients undergoing off-pump coronary artery bypass surgery. METHODS: Patients undergoing off-pump coronary artery bypass surgery at Abbott Northwestern Hospital, Minneapolis, Minn, were administered tests of neuro-cognition (cognition and motor function), anxiety, depression, and quality of life preoperatively (within 72 hours of surgery) and postoperatively (at least 72 hours after surgery but before discharge from the hospital). RESULTS: A total of 54 patients (79.6% men), mean age 64.5 years, completed tests both preoperatively and postoperatively. When baseline function was controlled for, increased age and new-onset atrial fibrillation (F(3,40)=42.97; P<.001) were associated with decreases in postoperative cognitive function; increased age and anxiety (F(3,35)=15.83; P<.001) were associated with decreases in postoperative motor function. CONCLUSION: Older patients, anxious patients, and patients with new-onset atrial fibrillation are at risk for neurocognitive changes after off-pump coronary artery bypass surgery. Further studies with larger sample sizes should be done to examine interventions to reduce preoperative anxiety in these patients. Interventions to prevent postoperative atrial fibrillation should be explored to determine whether the interventions prevent a decline in neurocognitive function.     

Early postoperative 30 degrees lateral positioning after coronary artery surgery: influence on cardiac output

Aims and objectives. We investigated whether: (i) Early postoperative lateral position after coronary artery bypass surgery may have a negative influence on the cardiac output and (ii) Whether turning procedures cause practical problems. Background. Directly following surgery, coronary artery bypass patients are not receiving routine turning every two hours to prevent pressure ulcers, because a negative influence on hemodynamic parameters is assumed. Design. Clinical trial. Methods. Fifty‐five coronary artery bypass patients were randomly assigned to four intervention regimens and underwent a two‐hour period of 30° lateral position. Fourteen patients in supine position served as a reference group. We hypothesized that 30° lateral position does not cause a relevant change in the cardiac output. Results. Turning the patients did not have any significant influence on the cardiac index, not even in the patients in a poor hemodynamic condition. The cardiac index in 30° lateral position and supine position two to eight hours postoperatively after coronary artery bypass surgery is statistically bioequivalent. No clinically relevant deviations from preset ‘safe’ values for mean arterial pressure, right atrial pressure, pulmonary artery wedge pressure and pulmonary arterial pressure were observed, which would require ending the lateral position. There were no practical problems hindering the turning regimen, not even in the patients with an intra‐aortic balloon pump. Conclusions. Early postoperative turning of coronary artery bypass surgery patients in lateral position is an easy and feasible procedure that does not influence the cardiac index not even in patients receiving antihypertensive or inotropic/vasopressor therapy. Further research is needed to find out whether our findings are also valid in other patient groups and other position conditions. Relevance to clinical practice. If there are no strict contra‐indications, lateral position has to be considered to prevent complications of continuous supine position within two hours after coronary artery bypass surgery patients have been admitted to the intensive care unit.     

Perioperative risk of patients undergoing noncardiac surgery after coronary artery bypass surgery

BACKGROUND: Most data suggesting that noncardiac surgery early after coronary artery bypass surgery carries low risk are derived from post hoc analyses of randomized controlled trials, with only limited data derived from contemporary, nonselected, and nontrial patients. METHODS: We retrospectively reviewed the medical records of patients who underwent coronary artery bypass surgery at our institution between January 1999 and October 2006 to determine whether they subsequently had major noncardiac surgery and what the outcomes of the noncardiac surgery were. RESULTS: During the study period, 1065 patients underwent coronary artery bypass surgery, and 272 (26%) subsequently underwent 467 major noncardiac surgeries. The mean interval from coronary artery bypass to noncardiac surgery was 1.9 +/- 1.9 years (range, 0-7.8 years). A major complication occurred in 3 surgeries (0.6% [95% confidence interval, 0.1%-1.9%]). Two patients died (both from respiratory arrest during the postoperative period: 1 patient had a tongue cancer excision, and the other patient had polycythemia vera), and the third patient had a perioperative arrhythmia. CONCLUSIONS: Noncardiac surgery is often required early after coronary artery bypass surgery and carries very low risk for cardiac complications, suggesting that preoperative cardiac evaluation may not be required in most such patients.     

Leucocyte-depleted cardioplegia does not reduce reperfusion injury in hypothermic coronary artery bypass surgery.

This study investigated the effects of leucocyte-depleted cardioplegia on postreperfusion oxidative stress and myocardial injury in elective hypothermic coronary artery bypass surgery. Forty patients were randomized to receive either cardioplegia with leucocytes depleted by an in-line Pall BC1B filter, or blood cardioplegia without leucocyte depletion. Transmyocardial oxidative stress was assessed by oxidized glutathione measurements in samples taken simultaneously from the coronary sinus and aortic root, and myocardial injury by postoperative CKMB and troponin-T measurements. The BC1B filters reduced numbers of cardioplegia leucocytes by a mean of 90.7%. Both patient groups demonstrated significant increases (p < 0.001) in transcardiac oxidized glutathione gradients after crossclamp release. No significant differences were found between the groups for postreperfusion oxidized glutathione gradients, postoperative levels of CKMB or troponin-T, or in the frequency of perioperative and postoperative complications. These results suggest that leucocyte-depleted cardioplegia does not significantly improve myocardial protection in patients undergoing elective coronary artery bypass surgery.     

Rhabdomyolysis in association with simvastatin and amiodarone

OBJECTIVE: To report a case of severe myopathy associated with concomitant simvastatin and amiodarone therapy. CASE SUMMARY: A 63-year-old white man with underlying insulin-dependent diabetes, recent coronary artery bypass surgery, and postoperative hemiplegia was treated with aspirin, metoprolol, furosemide, nitroglycerin, and simvastatin. Due to recurrent atrial fibrillation, oral anticoagulation with phenprocoumon and antiarrhythmic treatment with amiodarone were initiated. Four weeks after starting simvastatin 40 mg/day and 2 weeks after initiating amiodarone 1 g/day for 10 days, then 200 mg/day, he developed diffuse muscle pain with generalized muscular weakness. Laboratory investigations revealed a significant increase of creatine kinase (CK) peaking at 40 392 U/L. Due to a suspected drug interaction of simvastatin with amiodarone, both drugs were stopped. CK normalized over the following 8 days, and the patient made an uneventful recovery. An objective causality assessment revealed that the myopathy was probably related to simvastatin. DISCUSSION: Myopathy is a rare but potentially severe adverse reaction associated with statins. Besides high statin doses, concomitant use of fibrates, defined comorbidities, and concurrent use of inhibitors of cytochrome P450 are important additional risk factors. This is especially relevant if statins predominantly metabolized by CYP3A4 are combined with inhibitors of this isoenzyme. Amiodarone is a potent inhibitor of several different CYP isoenzymes, including CYP3A4. CONCLUSIONS: Avoiding the concomitant use of drugs with the potential to inhibit CYP-dependent metabolism (eg, amiodarone) or elimination of statins may decrease the risk of statin-associated myopathy. Alternatively, if drug therapy with a potent CYP inhibitor is inevitable, choosing a statin without relevant CYP metabolism (eg, pravastatin) should be considered.     

Resource utilization related to atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: Studies of resource utilization by patients with new-onset atrialfibrillation after coronary artery bypass grafting have addressed only length of stay and bed charges. OBJECTIVE: To compare resource utilization between patients with new-onset atrial fibrillation and patients without atrialfibrillation after isolated coronary artery bypass grafting. METHODS: Retrospective review of clinical and administrative electronic databases for 720 subjects who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass in 25 months at one medical center The prevalence of atrial fibrillation was determined, and resource utilization in various hospital cost centers was compared between subjects with and without atrialfibrillation. RESULTS: The prevalence of new-onset atrial fibrillation was 33.1%. Compared with subjects without atrialfibrillation, subjects with atrialfibrillation had a longer stay (5.8 +/- 2.4 vs. 4.4+/-1.2 days, P<.001), more days receiving mechanical ventilation (P =.002) and oxygen therapy (P<.001), and higher rates of readmission to the intensive care unit (4.6% vs. 0.2%, P<.001). Subjects with atrial fibrillation also had more laboratory tests (P<.001) and more days receiving cardiac drugs, heparin, diuretics, and electrolytes. Subjects with atrialfibrillation had higher total postoperative charges ($57261 +/- $17101 vs. $50905 +/- $10062, P = .001), a mean difference of $6356. The mean differences were greatest for bed charges ($1642), laboratory charges ($1215), pharmacy ($989), and respiratory care ($582). CONCLUSION: The economic impact of atrialfibrillation after coronary artery bypass grafting has been underestimated.     

非体外循环冠状动脉旁路移植术治疗冠状动脉粥样硬化性心脏病的体会

目的：总结非体外循环冠状动脉旁路移植术治疗冠状动脉粥样硬化性心脏病的疗效及围术期处理方法。方法：对63例冠状动脉粥样硬化性心脏病患者采用非体外循环冠状动脉旁路移植术治疗;患者冠状动脉旁路移植1～4支[（2.2±0.9）支]。非体外循环手术时间为2.0～5 h[（3.6±1.2）h];术中无改行体外循环冠状动脉旁路移植术,手术成功率100%,无手术死亡。结果：术后早期死亡2例,死亡原因为多器官功能衰竭,其余患者术后心绞痛、胸闷、气短等均有明显缓解,心肌缺血明显改善,随访6～60个月,均恢复良好,心功能Ⅰ～Ⅱ级。结论：非体外循环冠状动脉旁路移植术安全有效,严格掌握手术指证、熟练的外科手术技巧、妥善细致的围手术期处理,是提高手术成功率的关键。     

A hospital perspective on the cost-effectiveness of beta-blockade for prophylaxis of atrial fibrillation after cardiothoracic surgery

BACKGROUND: Prophylactic beta-blockade is the recommended strategy for suppressing atrial fibrillation after cardiothoracic surgery (CTS). However, beta-blockade's impact on the hospital length of stay (LOS) and other economic end points has not been adequately assessed. OBJECTIVE: The present evaluation sought to determine whether beta-blocker use after CTS is a cost-effective strategy for the prevention of postoperative atrial fibrillation (POAF). METHODS: This was a piggyback cost-effectiveness analysis of a prospective cohort evaluation comprising 1660 patients undergoing CTS at an urban academic hospital from October 1999 to October 2003. Patients receiving beta-blocker prophylaxis were matched 1:1 with control patients not receiving prophylaxis based on age >70 years, valvular surgery, history of atrial fibrillation, male sex, and use of preoperative digoxin or beta-blockers. The incidence of POAF, total hospital costs, and LOS were compared in each group. Nonparametric bootstrapping analysis was performed to examine the study results as part of a quadrant analysis and to calculate CIs for the incremental cost-effectiveness ratio. LOS and total costs were also compared in patients with and without POAF, regardless of beta-blocker use. RESULTS: Use of prophylactic beta-blockade was associated with a 17.3 % reduction in the incidence of POAF (P = 0.02) and a 2.2-day reduction in LOS (P = 0.001) compared with nonuse. It also was associated with a 25.7% reduction in total hospital costs compared with nonuse (mean [SD], $30,978 [$33,108] vs $41,700 [$67,369], respectively; P < 0.001), possibly due to a 27.6% reduction in room and board costs ($11,144 [$15,398] vs $14,920 [$22,132]; P < 0.001). In the bootstrapping analysis, 99.0% of the time prophylactic beta-blockade fell into quadrant IV, which indicated superior effectiveness and lower total costs. Regardless of beta-blocker use, patients who developed POAF had a significantly longer LOS compared with those who did not develop POAF (14.7 [19.1] days vs 10.1 [11.1] days, respectively; P < 0.001) and higher total costs ($47,240 [$85,941] vs $32,516 [$34,644]; P < 0.001). CONCLUSIONS: At the institution studied, beta-blocker prophylaxis against POAF after CTS was associated with significantly reduced total costs compared with nonuse of beta-blocker prophylaxis. Patients who developed POAF had significantly increased LOS and total costs compared with those who did not develop POAE An adequately powered prospective, randomized, placebo-controlled trial is necessary to confirm the results of this evaluation.     

Efficacy of amiodarone versus propafenone in the prevention of rhythm disorders in patients after aortocoronary bypass surgery

A prospective randomized study was conducted to compare the antiarrhythmic activity of amiodarone and propafenone used to prevent atrial fibrillation (AF) after aortocoronary bypass surgery (ACBS). The study included 100 patients who had undergone myocardial revascularization. The patients were divided into 2 groups that did not significantly differ in their baseline condition, history data, the type of a surgical intervention, and the incidence of postoperative complications. Antiarrhythmic therapy was initiated within the first 24 hours after surgery. Group 1 (n=50) was given intravenous amiodarone in a dose of 6 mg/kg/day. Rhythm disturbances occurred in 13 (26%) patients. Group 2 (n=50) received oral propaferone in a dose of 6.6 mg/kg/day. AF occurred in 5 (10%) patients. The difference between Groups 1 and 2 was statistically significant (p = 0.047). The preventive use of propafenone recovered sinus rhythm in earlier periods (4602 +/- 71 min) than that of amiodarone (760 +/- 82 min); p = 0.049. Thus, propafenone was found to be a more effective drug used to prevent AF after ACBS, which is attributable to different pharmacodynamic behavior of the agents.     

Increased plasma levels of pro-brain natriuretic peptide in patients with cardiovascular complications following off-pump coronary artery surgery

Objective To compare N-terminal pro-brain natriuretic peptide (NT-pro-BNP), procalcitonin (PCT), and troponin I (Tn I) concentrations during and after coronary artery surgery in patients with or without cardiovascular complications.Design and setting Prospective, comparative study of 12 months in the cardiovascular intensive care unit in a university hospitalPatients 60 adult patients undergoing coronary artery bypass grafting with the off-pump technique.Measurements and results Plasma NT-pro-BNP, PCT, and Tn I levels were measured before and immediately after the end of operation and on PODs 1, and 2 and 3. We defined complicated postoperative course as myocardial infarction, cardiogenic shock, arrhythmias, congestive heart failure, and death occurring after the fourth postoperative hour. Receiver operating characteristic (ROC) curve cutoff values were used to assess the ability of the three markers to predict future cardiac events. The area under ROC curve (AUC) using NT-pro-BNP to detect a cardiovascular complicated course was 0.780 at the preoperative time and 0.850 at the end of surgery. A preoperative NT-pro-BNP value of 397 pg/ml had a sensitivity of 76%, specificity of 67%, and accuracy of 74% for predicting a subsequent cardiovascular complication. An immediate postoperative NT-pro-BNP value of 430 pg/ml had a sensitivity of 80%, specificity of 77%, and accuracy of 76%. Patients with preoperative NT-pro-BNP levels less than 275 pg/ml had an excellent postoperative prognosis. Other two markers were less appropriate.Conclusions NT-pro-BNP levels measured before and immediately after off-pump coronary artery bypass seem to be predictive of postoperative cardiac events.     

Preoperative Anxiety and Depression Increases the Incidence of Delirium After Coronary Artery Bypass Graft Surgery

PurposeTo address the effect of anxiety and depression before coronary artery bypass graft surgery on the postoperative delirium and the length of hospitalization.DesignProspective cohort study.MethodsThe anxiety and depression before surgery was measured using the 14-item Hospital Anxiety and Depression Scale. The main outcome of interest was delirium, which was assessed at baseline and then on the second, third, fourth, and fifth days after surgery, using the nine-item Neecham Confusion Scale. The incidence of delirium was compared in the positive group (153 patients with anxiety and depression at baseline) versus the negative group (153 patients without anxiety and depression at baseline).FindingsThere was a significant difference between the mean score of delirium in the two groups on the second, third, fourth, and fifth days after surgery (P = .001). The incidence of mild and moderate/severe delirium was significantly higher in the positive group than in the negative group for the entire length of follow-up (P = .001). The average length of hospitalization was nearly the same in the two groups (P = .156).ConclusionsThis study indicated that anxiety and depression before coronary artery bypass graft surgery can significantly increase the incidence of postoperative delirium, but it has no significant effect on the length of hospitalization.     

Age and history of cardiac disease as risk factors for cardiac complications after peripheral vascular surgery in diabetic patients

OBJECTIVE: To examine the relationship of age and clinical factors to postoperative cardiovascular events in a cohort of diabetic patients undergoing peripheral vascular surgery. PATIENTS AND METHODS: In this cohort study, 316 diabetic patients were followed up prospectively after femoral-to-distal artery bypass surgery. The major end points of the study were all-cause mortality and cardiac morbidity (cardiac events defined as nonfatal myocardial infarction, unstable angina, and congestive heart failure). RESULTS: The overall postoperative cardiac event rate was 17.1% (54/316), with a 7.6% (24/316) rate of postoperative death or nonfatal myocardial infarction. Older diabetic patients (> or = 65 years) had a complication rate of 19.9% (43/216) compared with an 11.0% (11/100) complication rate in younger diabetic patients (< 65 years) (P = .02). Younger diabetic patients with a clinical history of coronary artery disease had an event rate of 18.2% (39/216) compared with an event rate of 2.4% (1/42) in younger diabetic patients without known cardiac disease (P = .02). In contrast, event rates were similar (20.7% [150/208] vs 18.2% [66/108]) in older diabetic patients with or without prior evidence of cardiac disease. CONCLUSION: Advanced age and clinical evidence of coronary artery disease are important determinants of postoperative outcome in diabetic patients undergoing peripheral vascular surgery.