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For hospitalists and other physicians performing cardiac risk stratification for noncardiac surgery patients, the current study does not warrant any change in current practice as recommended in the American College of Cardiology/American Heart Association Guidelines 2002.5 As to whether resting tachycardia should be considered as a predictive ECG criterion in this context, further valid and applicable evidence is needed.

References

1. De Bacquer D, De Backer G, Kornitzer M, et al. Prognostic value of ECG findings for total, cardiovascular disease, and coronary heart disease death in men and women. Heart. 1998 Dec;80(6):570-577.
2. Tervahauta M, Pekkanen J, Punsar S, et al. Resting electrocardiographic abnormalities as predictors of coronary events and total mortality among elderly men. Am J Med. 1996 Jun;100(6):641-645.
3. Filipovic M, Jeger R, Probst C, et al. Heart rate variability and cardiac troponin I are incremental and independent predictors of one-year all-cause mortality after major noncardiac surgery in patients at risk of coronary artery disease. J Am Coll Cardiol. 2003 Nov 19;42(10):1767-76.
4. Filipovic M, Jeger RV, Girard T, et al. Predictors of long-term mortality and cardiac events in patients with known or suspected coronary artery disease who survive major noncardiac surgery. Anaesthesia. 2005 Jan;60(1):5-11.
5. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary. Circulation. 2002 Mar 12;105(10):1257-1267.

Statins and Cardiovascular Disease

Hackam DG, Mamdani M, Li P, et al. Statins and sepsis in patients with cardiovascular disease: a population-based cohort analysis. Lancet. 2006 Feb 4;367(9508):413-418.

Background: The benefits of statins in secondary prevention of MI and ischemic CVA, as well as in reduction of all-cause mortality and their primary prevention in diabetics, are well documented in the literature.1 The concept of statins reducing subsequent sepsis in humans with atherosclerotic cardiovascular disease (CVD) is relatively new. One hypothesis holds that such an effect may be due to several common pathophysiologic mechanisms of sepsis and CVD: endothelial instability, immune dysregulation, inflammation, and thrombogenesis. Statins have been shown to provide improved outcomes from sepsis in animal studies, and observational studies in humans have raised similar hypotheses. This study attempts to analyze whether statin use in humans is associated with similar benefits regarding prevention of sepsis.

Methods: This was a population-based cohort analysis of 141,487 patients in Ontario, Canada, during the period of time from 1997-2002, who were older than age 65 and had been hospitalized for acute coronary syndrome or ischemic stroke, or had revascularization and survived three months post discharge. Using four reputable linked administrative databases, the authors found that 46,662 (33%) patients were prescribed a statin within three months of the discharge date (the index date), and 94,825 (67%) were not. About 19% of enrolled patients died within nine months and were excluded from the analysis. Of the eligible patients, propensity-based matching was used to identify 69,168 patients, of whom half were prescribed a statin and half were not. The patients were then analyzed through provincial administrative databases for the end points of hospital admission with an International Classification of Disease (ICD) code of sepsis, severe sepsis, fatal sepsis, death, or the end of the study.

Results: A total of 551 out of 34,584 patients were admitted for sepsis from the statin group, and 667 out of 34,584 were admitted from the control group during a mean follow-up of 2.2 years. The rate of sepsis in the statin group was significantly lower than in the control group (71.2 versus 88.0 per 10,000 person-years; p=0.0003). Statin use was also associated with fewer episodes of sepsis in an extended duration of 3.8 years, and with a lower risk of severe and fatal sepsis where sepsis was the admission diagnosis. This protection was evident at both high and low doses. The hazard ratio for sepsis was .81. There was a 19% relative reduction in the risk of sepsis in patients older than 65 with atherosclerosis. The absolute risk reduction for the occurrence of sepsis per 10,000 person-years was 16.8%, or .168% per person-year, with a corresponding number needed to treat (NNT) of 595 patients to prevent one episode of sepsis per year.