There was an increased adjusted odds of mortality for current smokers with <10 pack-years, while the effects on arterial and respiratory events increased incrementally with increased pack-years. Smoking was associated with adverse post-op outcomes regardless of smoking-related diseases. Variability in hospital quality or surgical strategies may have confounded the results.
Bottom line: Among patients undergoing major surgery, current but not past smoking was associated with higher mortality; smoking cessation for at least a year prior to surgery may decrease post-operative adverse events.
Citation: Musallam KM, Rosendaal FR, Zaatari G, et al. Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery. JAMA Surg. 2013 Jun 19:1-8. doi: 10.1001/jamasurg.2013.2360 [Epub ahead of print].
Statins Associated with Several Musculoskeletal Conditions
Clinical question: Is statin use associated with musculoskeletal adverse events, including arthropathy and injury, in physically active individuals?
Background: Statin-induced musculoskeletal adverse events (AEs) include myalgias, muscle weakness, cramps, rhabdomyolysis, and tendinous disease. The full spectrum of AEs is unknown because randomized clinical trials have not been powered to detect uncommon AEs.
Study design: Retrospective cohort study with propensity score matching.
Setting: San Antonio military area.
Synopsis: A total of 46,249 patients aged 30 to 85 years who met study criteria were propensity-matched into 6,967 statin users and 6,967 nonusers. The occurrence of musculoskeletal conditions were categorized using ICD-9 codes: Msk1, all musculoskeletal diseases; Msk1a, arthropathies and related diseases; Msk1b, injury-related diseases; and Msk2, drug-associated musculoskeletal pain. Of these, statin users had a higher odds ratio (OR) for Msk1 (OR 1.19; 95% CI, 1.08-1.30), Msk1b (1.13; 1.05-1.21), and Msk2 (1.09; 1.02-1.18). Msk1b (arthropathies) had an OR of 1.07 (0.9-1.16, P=0.07). Simvastatin was used by 73.5% of patients, and years of simvastatin use was not a significant predictor of any of the outcome measures. Secondary and sensitivity analyses showed higher adjusted ORs for statin users in all groups. This study was limited by the use of ICD-9-CM codes for identification of baseline characteristics, and the musculoskeletal diagnosis groups used were not validated.
Bottom line: Statin use is associated with an increased likelihood of musculoskeletal conditions, arthropathies, injuries, and pain.
Citation: Mansi I, Frei CR, Pugh M, Makris U, Mortensen EM. Statins and musculoskeletal conditions, arthropathies, and injuries. JAMA Intern Med. 2013;173:1318-1326.
Evidence-Based Guidelines on Periprocedural Management of Antithrombotic Medications in Patients with History of Stroke
Clinical question: What is the evidence for the periprocedural management of antithrombotics in patients with ischemic cerebrovascular accidents (CVAs)?
Background: Evidence-based guidelines are needed to help clinicians determine the thromboembolic risk of temporary discontinuation of antithrombotic medications, the perioperative bleeding risks of continuing antithrombotic agents, whether bridging therapy should be used, and the appropriate timing of antithrombotic agent discontinuation.
Study design: Systematic literature review with practice recommendations.
Setting: American Academy of Neurology Guideline Development Subcommittee convened an expert panel to review and provide recommendations.
Synopsis: Researchers analyzed 133 literature reviews via MEDLINE and EMBASE. Aspirin in stroke patients:
- Should routinely be continued for dental procedures (Level A);
- Should probably be continued for invasive ocular anesthesia, cataract surgery, dermatologic procedures, transrectal ultrasound-guided prostate biopsy, spinal/epidural procedures, and carpal tunnel surgery (Level B); and
- Should possibly be continued for vitreoretinal surgery, electromyogram (EMG), transbronchial lung biopsy, colonoscopic polypectomy, upper endoscopy and biopsy/sphincterotomy, and abdominal ultrasound-guided biopsies (Level C).
Warfarin in stroke patients:
- Should routinely be continued for dental procedures (Level A); and
- Should possibly continued for dermatologic procedures (Level B) and EMG, prostate procedures, inguinal hemiorrhaphy, and endothermal ablation of great saphenous vein (Level C).
- There is a lack of evidence on warfarin for ophthalmologic procedures, with the exception of ocular anesthesia, where it probably does not increase clinically significant bleeding (Level B).