- Email: [email protected]
Regarding “Howell SJ, Vohra RS. Perioperative Management of Patients Undergoing Non-cardiac Vascular Surgery. Eur J Vasc Endovasc Surg 2007;34:625–631”.
Eur J Vasc Endovasc Surg 35, 379e380 (2008) doi:10.1016/j.ejvs.2007.10.024, available online at http://www.sciencedirect.com on
CORRESPONDENCE
Regarding ‘‘Howell SJ, Vohra RS. Perioperative Management of Patients Undergoing Non-cardiac Vascular Surgery. Eur J Vasc Endovasc Surg 2007;34: 625e631’’. The comprehensive review by Howell and Vohra describes several strategies for the optimisation of the perioperative management of patients undergoing non-cardiac vascular surgery.1 An issue which could possibly be addressed more extensively is statin therapy. Statin treatment has been suggested to improve perioperative, as well as long-term, morbidity and mortality rates in patients undergoing non-cardiac vascular surgery.2 Statins are also associated with fewer cardiovascular complications and a shorter length of inhospital stay compared with non-users.2 Furthermore, statins exhibit multiple non-lipid related properties, including anti-inflammatory and anti-atherosclerotic actions, in addition to reducing cardiovascular events.2,3 Since vascular patients usually have arterial disease affecting >1 territory,1e3 statins should be used to manage atherosclerosis and exert their pleiotropic effects in other vascular beds as well. The need for randomised controlled trials is unquestionable.1e3 However, ethical restrictions due to the reported benefits of statin treatment may render not possible the performance of such trials. Current evidence suggests that statins are safe and costeffective agents that should be employed in the medical and surgical management of vascular patients.2,3 While expecting the results of randomised trials, it seems reasonable to include statins in the perioperative management of these patients. K.I. Paraskevas* Department of Clinical Biochemistry (Vascular Disease Prevention Clinic), and Academic Department of Surgery, Royal Free Hospital, London, UK E-mail address: [email protected]
DOI of original article: 10.1016/j.ejvs.2007.06.020. *Corresponding author.
References 1 HOWELL SJ, VOHRA RS. Perioperative management of patients undergoing non-cardiac vascular surgery. Eur J Vasc Endovasc Surg 2007;34:625e631. 2 PARASKEVAS KI, LIAPIS CD, HAMILTON G, MIKHAILIDIS DP. Can statins reduce perioperative morbidity and mortality in patients undergoing non-cardiac vascular surgery? Eur J Vasc Endovasc Surg 2006;32:286e293. 3 GOLLEDGE J, POWELL JT. Medical management of abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2007;34:267e273. Accepted 29 October 2007 Available online 3 January 2008
doi:10.1016/j.ejvs.2007.11.010, available online at http://www.sciencedirect.com on
Will There Ever be a Randomised Control Trial (RCT) Studying the Effects of Statins on Patients Undergoing Non-cardiac Vascular Surgery (NCVS)? We thank Dr. Paraskevas for his response. As he notes, statin therapy appears to improve perioperative and long-term morbidity and mortality in patients undergoing NCVS.1 A large RCT is needed to confirm these findings. Many patients who would be candidates for such a trial have a primary or secondary indication for statin administration2 making it difficult to randomise them. In addition some feel that a shift in emphasis from risk stratification to risk modification with therapeutic interventions, including statin administration should be adopted.3 A major concern of perioperative statin therapy has been the risk of elevated serum transaminases, myopathy and rhabdomyolysis. While elevated transaminases are frequently observed, there is little evidence that statins cause progressive liver disease.4 However the risk of myopathy and rhabdomyolysis are increased with commonly used concomitant drugs including macrolide antibiotics, digoxin and warfarin.4 In addition the risk of these potentially fatal complications maybe further potentiated by dehydration in the perioperative period.
1078–5884/000379 + 02 $34.00/0 Ó 2007 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
CORRESPONDENCE
Regarding ‘‘Howell SJ, Vohra RS. Perioperative Management of Patients Undergoing Non-cardiac Vascular Surgery. Eur J Vasc Endovasc Surg 2007;34: 625e631’’. The comprehensive review by Howell and Vohra describes several strategies for the optimisation of the perioperative management of patients undergoing non-cardiac vascular surgery.1 An issue which could possibly be addressed more extensively is statin therapy. Statin treatment has been suggested to improve perioperative, as well as long-term, morbidity and mortality rates in patients undergoing non-cardiac vascular surgery.2 Statins are also associated with fewer cardiovascular complications and a shorter length of inhospital stay compared with non-users.2 Furthermore, statins exhibit multiple non-lipid related properties, including anti-inflammatory and anti-atherosclerotic actions, in addition to reducing cardiovascular events.2,3 Since vascular patients usually have arterial disease affecting >1 territory,1e3 statins should be used to manage atherosclerosis and exert their pleiotropic effects in other vascular beds as well. The need for randomised controlled trials is unquestionable.1e3 However, ethical restrictions due to the reported benefits of statin treatment may render not possible the performance of such trials. Current evidence suggests that statins are safe and costeffective agents that should be employed in the medical and surgical management of vascular patients.2,3 While expecting the results of randomised trials, it seems reasonable to include statins in the perioperative management of these patients. K.I. Paraskevas* Department of Clinical Biochemistry (Vascular Disease Prevention Clinic), and Academic Department of Surgery, Royal Free Hospital, London, UK E-mail address: [email protected]
DOI of original article: 10.1016/j.ejvs.2007.06.020. *Corresponding author.
References 1 HOWELL SJ, VOHRA RS. Perioperative management of patients undergoing non-cardiac vascular surgery. Eur J Vasc Endovasc Surg 2007;34:625e631. 2 PARASKEVAS KI, LIAPIS CD, HAMILTON G, MIKHAILIDIS DP. Can statins reduce perioperative morbidity and mortality in patients undergoing non-cardiac vascular surgery? Eur J Vasc Endovasc Surg 2006;32:286e293. 3 GOLLEDGE J, POWELL JT. Medical management of abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2007;34:267e273. Accepted 29 October 2007 Available online 3 January 2008
doi:10.1016/j.ejvs.2007.11.010, available online at http://www.sciencedirect.com on
Will There Ever be a Randomised Control Trial (RCT) Studying the Effects of Statins on Patients Undergoing Non-cardiac Vascular Surgery (NCVS)? We thank Dr. Paraskevas for his response. As he notes, statin therapy appears to improve perioperative and long-term morbidity and mortality in patients undergoing NCVS.1 A large RCT is needed to confirm these findings. Many patients who would be candidates for such a trial have a primary or secondary indication for statin administration2 making it difficult to randomise them. In addition some feel that a shift in emphasis from risk stratification to risk modification with therapeutic interventions, including statin administration should be adopted.3 A major concern of perioperative statin therapy has been the risk of elevated serum transaminases, myopathy and rhabdomyolysis. While elevated transaminases are frequently observed, there is little evidence that statins cause progressive liver disease.4 However the risk of myopathy and rhabdomyolysis are increased with commonly used concomitant drugs including macrolide antibiotics, digoxin and warfarin.4 In addition the risk of these potentially fatal complications maybe further potentiated by dehydration in the perioperative period.
1078–5884/000379 + 02 $34.00/0 Ó 2007 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.