Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac vascular surgery

ST-segment resolution but was associated with more transfusions and non-cerebral bleeding. Perspective: Two recent large scale studies, GUSTO V and ASSENT 3, have failed to show mortality benefit with the combination of abciximab and thrombolytic therapy, although reinfarction rates were reduced. It remains to be seen whether the beneficial angiographic effects of the combination of double bolus eptifibatide plus half-dose TNK observed in this study translate into mortality benefit in a large-scale randomized clinical trial. RM

ever, until such data are available, many experts believe that patients with STEMI 75 years or older should be treated with primary percutaneous coronary intervention, and in the absence of such a facility, with fibrinolytic agents if not contraindicated. RM

Statins Are Associated With a Reduced Incidence of Perioperative Mortality in Patients Undergoing Major Noncardiac Vascular Surgery Poldermans D, Bax JJ, Kertai MD, et al. Circulation 2003;107: 1848 –51.

Fibrinolytic Therapy in Patients 75 Years and Older With ST-Segment-Elevation Myocardial Infarction. One-Year Follow-up of a Large Prospective Cohort

Study Question: Do inhibitors of the 3-hydroxy-3-methylglutaryl coenzyme A (statins) reduce perioperative mortality in patients undergoing major vascular surgery? Methods: A case-controlled study among the 2816 patients who underwent major vascular surgery from 1991 to 2000 at the Erasmus Medical Center was performed to evaluate the association between statin use and perioperative mortality. Patients who died during hospital stay after surgery (cases, n⫽160 [5.8%]) patients were compared with controls from the remaining subjects, two controls being selected for each case stratified according to calendar year and type of surgery. Information was obtained for both groups regarding the presence of cardiac risk factors and the use of cardiovascular medications (including statins) before surgery. Results: Death from a vascular complication during the perioperative phase occurred in 65% of case subjects. Statin use was significantly less common in cases than in controls (8% vs. 25%; p⫽0.001). Perioperative mortality was lower among statin users as compared with nonusers (adjusted odds ratio 0.22, 95% confidence interval 0.10 – 0.47). Similar benefit of statin use was observed in subgroups of patients according to the use of cardiovascular therapy and the presence of cardiac risk factors. Conclusions: This case-controlled study suggests that statin use reduces perioperative mortality in patients undergoing major vascular surgery. Perspective: Statins have long been shown to be effective for secondary prevention of cardiovascular disease and are indicated in patients with vascular disease, irrespective of whether they are undergoing vascular surgery or not. Hence, the low rates of statins (8% in case and 25% in controls) seen in this study should stimulate physicians to increase their use. RM

Stenestrand U, Wallentin L, for the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA). Arch Intern Med 2003;163:965–71. Study Question: What are the risks/benefits of fibrinolytic therapy in patients with acute ST-elevation myocardial infarction (STEMI) in patients who are 75 years and older? Methods: The RIKS-HIA recorded every patient admitted to a coronary care unit in 64 hospitals during 1995 to 1999. The relationship between 1-year mortality (obtained by merging the RIKS-HIA data with the National Cause of Death Register) and bleeding in STEMI was evaluated using propensity (adjusting for multiple factors known to influence fibrinolytic therapy) and Cox regression analysis (adjusting for factors affecting survival). Results: A total of 3897 of 6891 patients over age 75 years received fibrinolytic therapy. Propensity score analysis identified age, use of oral anticoagulation on admission, history of prior stroke, sites with cardiac catheterization facility, hospital size, circulatory arrest on arrival, congestive heart failure, renal failure, use of diuretics before inclusion, diabetes, cancer within last 3 years, use of angiotensinconverting enzyme inhibitor before admission and previous MI (c statistics 0.66) with lower likelihood of receiving fibrinolytic therapy. After adjusting for covariates, including propensity score, fibrinolytic therapy was associated with lower 1-year mortality and nonfatal cerebral bleeding rate among elderly patients with STEMI (32% vs. 36%, relative risk 0.87, 95% confidence interval 0.80 – 0.94; p⫽0.001). Conclusions: In patients age 75 years or older, fibrinolytic therapy in patients with STEMI is associated with a lower incidence of 1-year death and cerebral bleeding rate (composite), supporting the use of these agents in this cohort. Perspective: Thrombolytic therapy was given to low-risk patients as demonstrated by the propensity analysis. Despite adjustments for 29 covariates and propensity scores, it is unlikely that such adjustments could account for all confounders, particularly those not measured. As such, the beneficial effects of fibrinolytic therapy in this age group needs to be confirmed in randomized clinical trials. How-

Long-Term, Low-Intensity Warfarin Therapy for the Prevention of Recurrent Venous Thromboembolism Ridker P, Goldhaber SZ, Danielson E, et al., for the PREVENT Investigators. N Engl J Med 2003;348:1425–34. Study Question: Is there a value to long-term and lowintensity warfarin for the prevention of recurrent venous thrombosis and/or pulmonary emboli (VTE) in men and

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