The median time to surgery was 72 hours. Patients with more medical comorbidities and poorer preoperative functional status had longer delays to operation, most commonly due to interrupting antiplatelet treatment or need for preoperative “echocardiography or other examinations.” When these medical factors were included in logistic regression analysis, the increased mortality seen with delays of surgery in the cohort was no longer statistically significant, suggesting the underlying comorbidities of these patients, rather than the delay to surgery itself, explained the increased mortality.
Bottom line: Delaying hip fracture surgery is less important than preoperative functional status and medical comorbidity in contributing to poor outcomes.
Citation: Vidán MT, Sánchez E, Gracia Y, Marañón E, Vaquero J, Serra JA. Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med. 2011;155:226-233.
Beta-Blockers Decrease All-Cause and Cardiovascular Mortality in Patients with Chronic Kidney Disease
Clinical question: Are beta-blockers as effective in patients on dialysis and with end-stage chronic kidney disease (CKD) as they are in patients without severe renal disease?
Background: Patients with CKD have been largely excluded from trials of beta-blocker therapy even though they have high rates of cardiovascular disease and might be most likely to benefit. However, patients on dialysis might be predisposed to adverse complications of beta-blocker therapy, including hypotension.
Study design: Meta-analysis of eight trials of beta-blockade versus placebo (six heart failure trials) or ACE-I (two non-heart-failure trials) that included post-hoc analyses of CKD patients.
Setting: Varied, usually multinational RCTs.
Synopsis: The six congestive heart failure (CHF) studies were not designed to evaluate patients with CKD, and the two non-CHF studies were intended to evaluate progression of CKD, not cardiac outcomes. Thus, this is a meta-analysis of post-hoc CKD subgroups included in these trials. Compared with placebo, beta-blockers reduced all-cause and cardiovascular mortality without significant heterogeneity between trials. The magnitude of the effect was similar in CKD and non-CKD patients. Patients with CKD treated with beta-blockers were at increased risk of bradycardia and hypotension, but this did not lead to increased discontinuation of the drug. Only 114 dialysis patients were included in one of the eight trials (7,000 patients overall) and no outcomes were assessed.
Bottom line: Beta-blockers lower all-cause and cardiovascular mortality in patients with CKD similarly to patients without kidney disease but are associated with an increased risk for hypotension and bradycardia. Their effect in dialysis patients is unknown.
Citation: Badve SV, Roberts MA, Hawley CM, et al. Effects of beta-adrenergic antagonists in patients with chronic kidney disease: a systematic review and meta-analysis. J Am Coll Cardiol. 2011;58:1152-1161.
Daily Long-Term Azithromycin in COPD Patients Decreases Frequency of Exacerbations
Clinical question: Does long-term treatment with azithromycin decrease COPD exacerbations and improve quality of life with an acceptable risk profile?
Background: Patients with acute exacerbations of COPD have increased risks of death and more rapid decline in lung function. Macrolide antibiotics might decrease exacerbations via antibacterial and anti-inflammatory effects. Small studies of long-term treatment with macrolides in COPD have had conflicting results.
Study design: Prospective, multicenter, parallel-group, placebo-controlled trial.
Setting: Twelve U.S. academic health centers.
Synopsis: Eligible patients were those older than 40 with pulmonary function test-proven obstructive disease, a significant smoking history, a use of supplemental oxygen, or an oral glucocorticoid treatment in the previous year, and those who had previously come to healthcare attention for a COPD exacerbation. They were randomized to daily azithromycin (250 mg) or placebo. The primary outcome was time to first COPD exacerbation at one year. The investigators used deep nasopharyngeal swabs to evaluate the development of microbial resistance, and all patients were regularly screened for hearing loss. Time to first exacerbation and frequency of exacerbations decreased significantly with azithromycin treatment; the number needed to treat to prevent a COPD exacerbation was 2.86. More than half of nasopharyngeal samples had evidence of macrolide resistance at enrollment, and this increased to more than 80% at one year. Audiometric testing did show a decrease in hearing in those treated with azithromycin, but even those who did not stop their medication had recovery on subsequent testing.