Peritoneal Metastases from Gastroenteropancreatic Neuroendocrine Tumors: Incidence, Risk Factors and Prognosis.

BACKGROUND: Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are rare neoplasms and data on peritoneal metastases (PM) from these tumors are scarce. OBJECTIVE: The aim of this study was to present population-based data on the incidence, risk factors, and survival of synchronous PM in GEP-NETs. METHODS: Data from all patients diagnosed with a GEP-NET during 2007-2013 were collected from the Netherlands Cancer Registry. Age-standardized incidence rates were calculated and risk factors for developing PM were determined using multivariable logistic regression analysis. Survival was investigated using Kaplan-Meier and Cox regression analyses. RESULTS: A total of 4114 patients were diagnosed with a GEP-NET. PM were diagnosed in 234 patients (19% of patients with metastasized disease, representing 6% of all GEP-NETs). The incidence of patients diagnosed with PM was 1.6:1,000,000 persons per year. Risk factors for developing PM were higher age (odds ratio [OR] 1.4, 95% CI 1.0-2.0) and primary tumor location in the small intestine (OR 3.5, 95% CI 2.1-5.7) or colon (OR 2.5, 95% CI 1.4-4.4). Small intestinal NETs with PM had the best survival, while appendiceal NETs with PM had the poorest survival (5-year survival rates of 67 and 7%, respectively). Multivariate analysis showed that survival in patients with PM was worse compared with patients without metastases; however, the presence of PM among all metastasized patients was not associated with worse survival. CONCLUSIONS: This nationwide population-based study provides relevant insight into the incidence and risk factors of PM in GEP-NETs, and reveals detailed site-specific data on the presence of PM and survival data that may contribute to develop individualized treatment strategies in patients with these heterogeneous neoplasms.

Pancreatic cancer surgery in elderly patients: Balancing between short-term harm and long-term benefit. A population-based study in the Netherlands.

BACKGROUND: At a national level, it is unknown to what degree elderly patients with pancreatic or periampullary carcinoma benefit from surgical treatment compared to their younger counterparts. We investigated resection rates and outcomes after surgical treatment among elderly patients. METHODS: From the Netherlands Cancer Registry, 20 005 patients diagnosed with primary pancreatic or periampullary cancer in 2005-2013 were selected. The associations between age (<70, 70-74, 75-79, ≥80 years) and resection rates were investigated using χ(2) tests, and surgical outcomes (30-, 90-day mortality) were evaluated using logistic regression analysis. Overall survival after resection was investigated by means of Kaplan-Meier and Cox proportional hazard regression analysis. RESULTS: During the study period, resection rates increased in all age groups (<70 years: 20-30%, p < 0.001; ≥80 years: 2-8%, p < 0.001). Of 3845 patients who underwent tumour resection for pancreatic or periampullary carcinoma, the proportion of octogenarians increased from 3.5% to 5.5% (p = 0.03), whereas postoperative mortality did not increase (30-day: 6-3%, p = 0.06; 90-day: 9-8%, p = 0.21). With rising age, 30-day postoperative mortality increased (4-5-7-8%, respectively, p < 0.001), while 90-day mortality was 6-10-13-12% (p < 0.001) and three-year overall survival rates after surgery were 35-33-28-31%, respectively (p < 0.001). After adjustment for confounding factors, octogenarians who survived 90 days postoperative exhibited an overall survival close to younger patients [hazard ratio (≥80 vs. <70 years) = 1.21, 95% confidence interval (0.99-1.47), p = 0.07]. CONCLUSION: Despite higher short-term mortality, octogenarians who underwent pancreatic resection showed long-term survival similar to younger patients. With careful patient screening and counselling of elderly patients, a further increase of resection rates may be combined with improved outcomes.

Influence of comorbidity and age on 1-, 2-, and 3-month postoperative mortality rates in gastrointestinal cancer patients.

BACKGROUND: Studies on the impact of comorbidity and age on postoperative outcome after gastrointestinal tumor resection are scarce. In this study we investigated the impact of comorbidity and age on 30-, 60-, and 90-day mortality after resection of esophageal, gastric, periampullary, colon, and rectal cancer. METHODS: The study included 8,583 patients recorded in the population-based Netherlands Cancer Registry, regions Eindhoven (Eindhoven Cancer Registry) and Mid and South Limburg, who underwent resection for cancer stage I-III. Patients were diagnosed between 2005 and 2010. Age was categorized as <65, 65-74, and ≥75 years. RESULTS: Comorbidity was present in more than two-thirds (n = 5,910) of patients. The 30-day mortality rates ranged from 0.5 % for rectal cancer patients <65 years to 12.8 % for gastric cancer patients ≥75 years. Patients with comorbidity who underwent esophageal tumor resection had the highest mortality rates, ranging from 8.4 % for 30-day to 12.0 % for 90-day mortality, while rectal cancer patients had the lowest rates, that is, 4.3-6.4 %, respectively. In multivariable analyses, cardiac disease (odds ratio [OR] = 1.74, 95 % confidence interval [95 % CI] = 1.32-2.30), vascular disease (OR = 1.41, 95 % CI = 1.02-1.95) and previous malignancies (OR = 1.38, 95 % CI = 1.02-1.86) in colon cancer, and cardiac disease (OR = 1.81, 95 % CI = 1.10-2.98) and vascular disease (OR = 1.95, 95 % CI = 1.11-3.42) in rectal cancer were associated with the highest 30-day mortality. CONCLUSIONS: Postoperative mortality extends beyond 30 days. Comorbidity and older age are associated with early postoperative mortality after gastrointestinal cancer resection. Underlying comorbidity should be identified preoperatively with attention to patients' specific needs to optimally attenuate risk prior to surgery. A less aggressive treatment approach may well be considered in these groups.

The hospital standardized mortality ratio fallacy: a narrative review.

BACKGROUND: Outcome measures, like hospital standardized mortality ratios (HSMRs), are increasingly used to assess quality of care. The validity of HSMRs and their accuracy to reflect quality of care is heavily contested. OBJECTIVE: We explored apparent and potential shortcomings and adverse effects of the HSMR in the assessment of quality of care. RESEARCH DESIGN AND METHODS: For this narrative review, relevant articles were collected from Medline databases using the following search terms: "hospital standardized mortality ratio," "standardized mortality ratio," "HSMR," "quality of care," and "in-hospital mortality." In addition, other important articles were subtracted from the reference lists of the primary articles. RESULTS: The current literature exhibits important shortcomings of the HSMR that in particular affect hospitals providing specialized care of a certain level of complexity. Because of the lack or insufficiency of data concerning case-mix, coding variation between hospitals, disease severity, referral bias, end-of-life care, and place of death, the current HSMR model is not able to adjust adequately for these aspects. This leads to incomparability of HSMRs between hospitals. Instead of separate aspects of continuity of care, all factors contributing to quality of care should be considered. CONCLUSIONS: Given the several shortcomings, use of the HSMR as an indicator of quality of care can be considered as a fallacy. Publication of the HSMR is not likely to lead to improvement of quality of care and might harm both hospitals and patients.

Epidural analgesia is associated with improved health outcomes of surgical patients with chronic obstructive pulmonary disease.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) have increased postoperative morbidity and mortality. Epidural analgesia (EDA) improves postoperative outcome but may worsen postoperative lung function. It is unknown whether patients with COPD benefit from EDA. The objective of this study was to determine whether patients with COPD undergoing major abdominal surgery benefit from EDA in addition to general anesthesia. METHODS: This cohort study included 541 consecutive patients with COPD who underwent major abdominal surgery between 1995 and 2007 at a university medical center. Propensity scores estimating the probability of receiving EDA were used in multivariate correction. The primary outcome was postoperative pneumonia and 30-day mortality. RESULTS: There were 324 patients (60%) who received EDA in addition to general anesthesia. The incidence of postoperative pneumonia (16% vs. 11%; P = 0.08) and 30-day mortality (9% vs. 5%; P = 0.03) was lower in patients who received EDA. After correction EDA was associated with improved outcome for postoperative pneumonia (OR 0.5; 95% CI: 0.3-0.9; P = 0.03). The strongest preventive effect was seen in patients with the most severe type of COPD. CONCLUSION: This study provides evidence that in patients with COPD who are scheduled for major abdominal surgery, epidural analgesia decreases postoperative pulmonary complications.

Relation between preoperative and intraoperative new wall motion abnormalities in vascular surgery patients: a transesophageal echocardiographic study.

BACKGROUND: Coronary revascularization of the suspected culprit coronary lesion assessed by preoperative stress testing is not associated with improved outcome in vascular surgery patients. METHODS: Fifty-four major vascular surgery patients underwent preoperative dobutamine echocardiography and intraoperative transesophageal echocardiography. The locations of left ventricular rest wall motion abnormalities and new wall motion abnormalities (NWMAs) were scored using a seven-wall model. During 30-day follow-up, postoperative cardiac troponin release, myocardial infarction, and cardiac death were noted. RESULTS: Rest wall motion abnormalities were noted by dobutamine echocardiography in 17 patients (31%), and transesophageal echocardiography was noted in 16 (30%). NWMAs were induced during dobutamine echocardiography in 17 patients (31%), whereas NWMAs were observed by transesophageal echocardiography in 23 (43%), kappa value = 0.65. Although preoperative and intraoperative rest wall motion abnormalities showed an excellent agreement for the location (kappa value = 0.92), the agreement for preoperative and intraoperative NWMAs in different locations was poor (kappa value = 0.26-0.44). The composite cardiac endpoint occurred in 14 patients (26%). CONCLUSIONS: There was a poor correlation between the locations of preoperatively assessed stress-induced NWMAs by dobutamine echocardiography and those observed intraoperatively using transesophageal echocardiography. However, the composite endpoint of outcome was met more frequently in relation with intraoperative NWMAs.

Health-related quality of life predicts long-term survival in patients with peripheral artery disease.

We examined whether health-related quality of life (HRQoL) predicts long-term survival in patients with peripheral artery disease (PAD) independent of established prognostic risk factors. In 2004, data on 711 consecutive patients with PAD undergoing vascular surgery were collected from 11 hospitals in The Netherlands. After 1 year, patients were contacted to complete the EuroQol Questionnaire (EQ-5D), of which 503 complied. HRQoL assessed by the EQ-5D was divided into tertiles (i.e. poor, intermediate and good HRQoL). Mortality was subsequently assessed 3 years after surgery. Of the 503 patients, 55 (11%) patients died during follow-up. Mortality was 21% in patients with poor HRQoL, 8% in patients with intermediate HRQoL, and 5% in patients with good HRQoL. Patients with poor HRQoL (HR = 5.4; 95% CI 2.3-12.5) had a worse survival compared to patients with a good HRQoL, after adjusting for established prognostic factors. In conclusion, the study indicates that poor HRQoL predicts long-term survival in patients with PAD, and provides prognostic value above established risk factors.

Predictive value of NT-proBNP in vascular surgery patients with COPD and normal left ventricular systolic function.

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is commonly used to identify a cardiac cause of dyspnoea. However, patients with chronic obstructive pulmonary disease (COPD) may also have increased plasma NT-proBNP levels because of right-sided myocardial stress caused by pulmonary hypertension. We investigated the relationship between COPD and elevated NT-proBNP levels as well as the impact of elevated NT-proBNP levels on mortality in vascular surgery patients with normal left ventricular systolic function. Prior to vascular surgery, NT-proBNP levels, pulmonary function and left ventricular ejection fraction (LVEF) were assessed in 376 patients. Only patients with a LVEF > 40% were included; n = 261. Elevated NT-proBNP levels were defined as > or =500 pg/ml. Firstly, we assessed the relationship between COPD and NT-proBNP levels. Secondly, we investigated the association between elevated NT-proBNP levels and one-year mortality. COPD was independently associated with elevated NT-proBNP levels (OR 3.36, 95%CI 1.30-8.65) with significant associations found for mild and severe COPD. Elevated NT-proBNP levels were associated with increased one-year mortality in patients with (HR 7.73, 95%CI 1.60-37.43) and without COPD (HR 3.44, 95%CI 1.10-10.73). COPD was associated with elevated NT-proBNP levels in patients with a normal LVEF undergoing vascular surgery. Elevated NT-proBNP levels independent of other well-established risk factors were associated with increased one-year mortality. NT-proBNP may be useful biomarker to risk stratify patients with COPD.

Preoperative oral glucose tolerance testing in vascular surgery patients: long-term cardiovascular outcome.

BACKGROUND: Diabetes mellitus (DM) is an important risk factor in vascular surgery patients, influencing late outcome. Screening for diabetes is recommended by fasting glucose measurement. Oral glucose tolerance testing (OGTT) could enhance the detection of patients with impaired glucose tolerance (IGT) and DM. AIM: To assess the additional value of OGTT on top of fasting glucose levels in vascular surgery patients to predict long-term cardiovascular outcome. METHODS: A total of 404 patients without signs or histories of IGT (plasma glucose 7.8-11.1 mmol/L) or DM (glucose >/=11.1 mmol/L) were prospectively included and subjected to OGTT. Cardiac risk factors were noted. Primary outcome was the occurrence of late cardiovascular events (composite of cardiovascular death, angina pectoris, myocardial infarction, percutaneous coronary intervention/coronary artery bypass grafting, or cerebral vascular accident/transient ischemic attack), and secondary outcome included all-cause and cardiovascular mortality rates, in survivors of vascular surgery. Median follow-up was 3.0 (interquartile range 2.4-3.8) years. RESULTS: Impaired glucose tolerance (n = 104) and DM (n = 43) were detected by fasting glucose levels in 26 (25%) and 12 (28%) patients, and by OGTT in 78 (75%) and 31 (72%) patients, respectively. During follow-up, 131 patients experienced a cardiovascular event. With multivariable analysis, patients with IGT showed a significant increased risk for cardiovascular events (hazard ratio 2.77, 95% CI 1.83-4.20) and mortality (hazard ratio 2.06, 95% CI 1.03-4.12). Patients with DM showed a nonsignificant increased risk for cardiovascular events. CONCLUSION: Vascular surgery patients with IGT or DM detected by preoperative OGTT have an increased risk of developing cardiovascular events and mortality during long-term follow-up. It is recommended that nondiabetic vascular surgery patients should be tested for glucose regulation disorders before surgery.

Intima media thickness of the common carotid artery in vascular surgery patients: a predictor of postoperative cardiovascular events.

BACKGROUND: Cardiovascular (CV) complications are the leading cause of morbidity and mortality in vascular surgery patients. The Revised Cardiac Risk (RCR) index, identifying cardiac risk factors, is commonly used for preoperative risk stratification. However, a more direct marker of the underlying atherosclerotic disease, such as the common carotid artery intimamedia thickness (CCA-IMT) may be of predictive value as well. The current study evaluated the prognostic value of the CCA-IMT for postoperative CV outcome. METHODS: In 508 vascular surgery patients, the CCA-IMT was measured using high-resolution B-mode ultrasonography. We recorded the RCR factors: ischemic heart disease, heart failure, cerebrovascular disease, diabetes mellitus, and renal dysfunction. Repeated Troponin T measurements and electrocardiograms were performed postoperatively. The study end point was the composite of 30-day CV events and long-term CV mortality. Multivariable regression analyses were used to assess the additional value of CCA-IMT for the prediction of cardiac events. RESULTS: In total, 30-day events and long-term cardiovascular mortality were noted in 122 (24%) and 81 (16%) patients, respectively. The optimal predictive value of CCA-IMT, using receiver-operating characteristic curve analysis, for the prediction of CV events was calculated to be 1.25 mm (sensitivity 70%, specificity 80%). An increased CCA-IMT was independently associated with 30-day CV events (OR 2.20, 95% CI 1.38-3.52) and long-term CV mortality (HR 6.88, 95% CI 4.11-11.50), respectively. CONCLUSIONS: This study shows that an increased CCA-IMT has prognostic value in vascular surgery patients to predict 30-day CV events and long-term CV mortality, incremental to the RCR index.

Association between chronic obstructive pulmonary disease and chronic kidney disease in vascular surgery patients.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is recognized as a source of systemic inflammation and is associated with the development of cardiovascular disease. However, little is known about the association between COPD and chronic kidney disease (CKD). Therefore, we investigated the relationship between COPD and CKD and the association between COPD and mortality in patients with CKD. METHODS: We conducted a cohort study of 3358 vascular surgery patients between 1990 and 2006. CKD was defined according to the Modification of Diet in Renal Disease equation as an estimated glomerular filtration rate (GFR) <60 mL/min/1.73 m(2). In addition, the patients were divided into three categories based on the baseline estimated GFR: > or =90 mL/min/1.73 m(2); 60-89 mL/min/1.73 m(2) and <60 mL/min/1.73 m(2). Multivariable logistic regression analysis was used to evaluate the independent association between prevalent COPD and CKD. RESULTS: The prevalence of COPD was inversely related to kidney function. COPD was present in 47, 38 and 32% of patients with an estimated GFR <60, 60-89 and > or =90 mL/min/1.73 m(2), respectively. COPD was independently associated with CKD (OR 1.22; 95% CI 1.03-1.44; P = 0.03). This association was strongest in patients with moderate COPD (OR 1.33; 95% CI 1.07-1.65; P = 0.01). Both moderate and severe COPD were associated with increased long-term mortality in patients with CKD (HR 1.27; 95% CI 1.03-1.56; P = 0.03 and HR 1.61; 95% CI 1.10-2.35; P = 0.01, respectively), compared to patients without COPD. CONCLUSIONS: Our findings indicate that COPD is moderately associated with CKD in a large cohort of vascular surgery patients. In addition, moderate and severe COPD are related to increased long-term mortality in patients with CKD.

Impact of cardioselective beta-blockers on mortality in patients with chronic obstructive pulmonary disease and atherosclerosis.

RATIONALE: beta-Blocker use is associated with improved health outcomes in patients with cardiovascular disease. There is a general reluctance to prescribe beta-blockers in patients with chronic obstructive pulmonary disease (COPD) because they may worsen symptoms. OBJECTIVES: We investigated the relationship between cardioselective beta-blockers and mortality in patients with COPD undergoing major vascular surgery. METHODS: We evaluated 3,371 consecutive patients who underwent major vascular surgery at one academic institution between 1990 and 2006. The patients were divided into those with and without COPD on the basis of symptoms and spirometry. The major endpoints were 30-day and long-term mortality after vascular surgery. Patients were defined as receiving low-dose therapy if the dosage was less than 25% of the maximum recommended therapeutic dose; dosages higher than this were defined as intensified dose. MEASUREMENTS AND MAIN RESULTS: There were 1,205 (39%) patients with COPD of whom 462 (37%) received cardioselective beta-blocking agents. beta-Blocker use was associated independently with lower 30-day (odds ratio, 0.37; 95% confidence interval, 0.19-0.72) and long-term mortality in patients with COPD (hazards ratio, 0.73; 95% confidence interval, 0.60-0.88). Intensified dose was associated with both reduced 30-day and long-term mortality in patients with COPD, whereas low dose was not. CONCLUSIONS: Cardioselective beta-blockers were associated with reduced mortality in patients with COPD undergoing vascular surgery. In carefully selected patients with COPD, the use of cardioselective beta-blockers appears to be safe and associated with reduced mortality.

Usefulness of hypertensive blood pressure response during a single-stage exercise test to predict long-term outcome in patients with peripheral arterial disease.

The prognostic value of a hypertensive blood pressure (BP) response is still unclear. Therefore, the prognostic value of a hypertensive BP response in patients during single-stage exercise testing for peripheral arterial disease (PAD) on long-term mortality and major adverse cerebrovascular and cardiac events (MACCEs) was investigated. In addition, effects of statin, beta-blocker, and aspirin use in patients with known or suspected PAD were studied. A total of 2,109 patients were enrolled in an observational prospective study from 1993 to 2005. Hypertensive BP response was defined as an increase in systolic BP > or = 55 mm Hg (95(th) percentile within our population) after a single-stage treadmill exercise test. The outcome was obtained by using the civil registries, and a questionnaire about cardiac events was sent to all survivals. Hypertensive BP response was associated with increased risk of long-term mortality (hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.12 to 1.80) and MACCEs (HR 1.47, 95% CI 1.09 to 1.97). After adjustments for clinical risk factors and propensity score, baseline statin use was associated with reduced risk of long-term mortality (HR 0.59, 95% CI 0.44 to 0.79), and statin, beta-blocker, and aspirin use were associated with reduced risk of MACCEs (HR 0.59, 95% CI 0.43 to 0.81; HR 0.75, 95% CI 0.60 to 0.95; HR 0.73, 95% CI, 0.57 to 0.92, respectively). In conclusion, hypertensive BP response at exercise in patients with known or suspected PAD is an important independent risk factor for all-cause long-term mortality and MACCEs, whereas statin, beta-blocker, and aspirin use were associated with an improved outcome.

Influence of renal function on the usefulness of N-terminal pro-B-type natriuretic peptide as a prognostic cardiac risk marker in patients undergoing noncardiac vascular surgery.

N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) is related to stress-induced myocardial ischemia and/or volume overload, both common in patients with renal dysfunction. This might compromise the prognostic usefulness of NT-pro-BNP in patients with renal impairment before vascular surgery. We assessed the prognostic value of NT-pro-BNP in the entire strata of renal function. In 356 patients (median age 69 years, 77% men), cardiac history, glomerular filtration rate (GFR, ml/min/1.73 m(2)), and NT-pro-BNP level (pg/ml) were assessed preoperatively. Troponin T and electrocardiography were assessed postoperatively on days 1, 3, 7, and 30. The end point was the composite of cardiovascular death, Q-wave myocardial infarction, and troponin T release. Multivariate analysis was used to evaluate the interaction between GFR, NT-pro-BNP and their association with postoperative outcome. Median GFR was 78 ml/min/1.73 m(2) and the median concentration of NT-pro-BNP was 197 pg/ml. The end point was reached in 64 patients (18%); cardiac death occurred in 7 (2.0%), Q-wave myocardial infarction in 34 (9.6%), and non-Q-wave myocardial infarction in 23 (6.5%). After adjustment for confounders, NT-pro-BNP levels and GFR remained significantly associated with the end point (p = 0.005). The prognostic value of NT-pro-BNP was most pronounced in patients with GFR > or =90 (odds ratio [OR] 1.18, 95% confidence interval [CI] 0.80 to 1.76) compared with patients with GFR 60 to 89 (OR 1.04, 95% CI 1.002 to 1.07), and with GFR 30 to 59 (OR 1.12, 95% CI 1.03 to 1.21). In patients with GFR <30 ml/min/1.73 m(2), NT-pro-BNP levels have no prognostic value (OR 1.00, 95% CI 0.99 to 1.01). In conclusion, the discriminative value of NT-pro-BNP is most pronounced in patients with GFR > or =90 ml/min/1.73 m(2) and has no prognostic value in patients with GFR <30 ml/min/1.73 m(2).

Association between serum uric acid and perioperative and late cardiovascular outcome in patients with suspected or definite coronary artery disease undergoing elective vascular surgery.

The role of uric acid as an independent marker of cardiovascular risk is unclear. Therefore, our aim was to assess the independent contribution of preoperative serum uric acid levels to the risk of 30-day and late mortality and major adverse cardiac event (MACE) in patients scheduled for open vascular surgery. In total, 936 patients (76% male, age 68 +/- 11 years) were enrolled. Hyperuricemia was defined as serum uric acid >0.42 mmol/l for men and >0.36 mmol/l for women, as defined by large epidemiological studies. Outcome measures were 30-day and late mortality and MACE (cardiac death or myocardial infarction). Multivariable logistic and Cox regression analysis were used, adjusting for age, gender, and all cardiac risk factors. Data are presented as odds ratios or hazard ratios, with 95% confidence intervals. Hyperuricemia was present in 299 patients (32%). The presence of hyperuricemia was associated with heart failure, chronic kidney disease, and the use of diuretics. Perioperatively, 46 patients (5%) died and 61 patients (7%) experienced a MACE. Mean follow-up was 3.7 years (range: 0 to 17 years). During follow-up, 282 patients (30%) died and 170 patients (18%) experienced a MACE. After adjustment for all clinical risk factors, the presence of hyperuricemia was not significantly associated with an increased risk of 30-day mortality or MACE, odds ratios of 1.5 (0.8 to 2.8) and 1.7 (0.9 to 3.0), respectively. However, the presence of hyperuricemia was associated with an increased risk of late mortality and MACE, with hazard ratios of 1.4 (1.1 to 1.7) and 1.7 (1.3 to 2.3), respectively. In conclusion, the presence of preoperative hyperuricemia in vascular patients is a significant predictor of late mortality and MACE.

Effect of statin therapy on mortality in patients with peripheral arterial disease and comparison of those with versus without associated chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) and peripheral arterial disease (PAD) are both inflammatory conditions. Statins are commonly used in patients with PAD and have anti-inflammatory properties, which may have beneficial effects in patients with COPD. The relation between statin use and mortality was investigated in patients with PAD with and without COPD. From 1990 to 2006, we studied 3,371 vascular surgery patients. Statin use was noted at baseline and, if prescribed, converted to <25% (low dose) and > or =25% (intensified dose) of the maximum recommended therapeutic dose. The diagnosis of COPD was based on the Global Initiative for Chronic Obstructive Lung Disease guidelines using pulmonary function test. End points were short- (30-day) and long-term (10-year) mortality. A total of 330 patients with COPD (25%) used statins, and 480 patients (23%) without COPD. Statin use was independently associated with improved short- and long-term survival in patients with COPD (odds ratio 0.48, 95% confidence interval [CI] 0.23 to 1.00; hazard ratio 0.67, 95% CI 0.52 to 0.86, respectively). In patients without COPD, statins were also associated with improved short- and long-term survival (odds ratio 0.42, 95% CI 0.20 to 0.87; hazard ratio 0.76, 95% CI 0.60 to 0.95, respectively). In patients with COPD, only an intensified dose of statins was associated with improved short-term survival. However, for the long term, both low-dose and intensive statin therapy were beneficial. In conclusion, statin use was associated with improved short- and long-term survival in patients with PAD with and without COPD. Patients with COPD should be treated with an intensified dose of statins to achieve an optimal effect on both the short and long term.

The obesity paradox in patients with peripheral arterial disease.

BACKGROUND: Cardiac events are the predominant cause of late mortality in patients with peripheral arterial disease (PAD). In these patients, mortality decreases with increasing body mass index (BMI). COPD is identified as a cardiac risk factor, which preferentially affects underweight individuals. Whether or not COPD explains the obesity paradox in PAD patients is unknown. METHODS: We studied 2,392 patients who underwent major vascular surgery at one teaching institution. Patients were classified according to COPD status and BMIs (ie, underweight, normal, overweight, and obese), and the relationship between these variables and all-cause mortality was determined using a Cox regression analysis. The median follow-up period was 4.37 years (interquartile range, 1.98 to 8.47 years). RESULTS: The overall mortality rates among underweight, normal, overweight, and obese patients were 54%, 50%, 40%, and 31%, respectively (p < 0.001). The distribution of COPD severity classes showed an increased prevalence of moderate-to-severe COPD in underweight patients. In the entire population, BMI (continuous) was associated with increased mortality (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94 to 0.98). In addition, patients who were classified as being underweight were at increased risk for mortality (HR, 1.42; 95% CI, 1.00 to 2.01). However, after adjusting for COPD severity the relationship was no longer significant (HR, 1.29; 95% CI, 0.91 to 1.93). CONCLUSIONS: The excess mortality among underweight patients was largely explained by the overrepresentation of individuals with moderate-to-severe COPD. COPD may in part explain the "obesity paradox" in the PAD population.

Statin therapy is associated with improved outcomes in vascular surgery patients with renal impairment.

BACKGROUND: Little is known about the association between baseline kidney function, statin therapy, and outcome after vascular surgery in patients with and without chronic kidney disease. METHODS: A total of 2126 patients underwent elective major vascular surgery and were divided into 2 categories based on baseline creatinine clearance (CrCl), calculated using the Cockcroft-Gault equation: CrCl > or = 60 mL/min (n = 1358, reference) and CrCl < 60 mL/min (n = 768). Outcome measures were 30-day and long-term all-cause, cardiac, and cerebrocardiovascular mortality. Mean follow-up was 6.0 +/- 3.7 years. Multivariate Cox regression analysis, including potential confounders and propensity score for statin use, was applied. Data are presented as hazard ratios (HRs) with 95% CI. RESULTS: Thirty-day all-cause, cardiac, and cerebrocardiovascular mortality rates were 3.8% versus 10.2%, 1.3% versus 4.2%, and 2.7% versus 7.8%, respectively, according to the 2 categories of kidney function. In addition, long-term all-cause, cardiac, and cerebrocardiovascular mortality rates were 46.6% versus 72.5%, 14.6% versus 26.4%, and 23.0% versus 40.6%, respectively. Statin therapy was associated with an overall significant improved 30-day and long-term all-cause mortality, independent of other important confounders. However, in patients with a CrCl > or = 60 mL/min, the long-term cardiac and cerebrocardiovascular beneficial effects did not reach statistical significance (HR 0.93, 95% CI 0.61-1.41 and HR 0.89, 95% CI 0.63-1.24, respectively) when compared with patients with a CrCl of < 60 mL/min (HR 0.63, 95% CI 0.41-0.96 and HR 0.67, 95% CI 0.48-0.94, respectively). CONCLUSIONS: The level of kidney function is an independent predictor of short- and long-term outcome after major noncardiac surgery. In addition, perioperative statin use in patients with kidney disease is associated with a reduction in the short- and long-term all-cause, cardiac, and cerebrocardiovascular mortality.

Temporary worsening of renal function after aortic surgery is associated with higher long-term mortality.

BACKGROUND: Little is known about acute changes in renal function in the postoperative period and the outcome of patients undergoing major vascular surgery. Specifically, data are scarce for patients in whom renal function temporarily decreases and returns to baseline at 3 days after surgery. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 1,324 patients who underwent elective open abdominal aortic aneurysm surgery in a single center. PREDICTOR: Renal function (creatinine clearance was measured preoperatively and on days 1, 2, and 3 after surgery. Patients were divided into 3 groups: group 1, improved or unchanged (change in creatinine clearance, +/-10% of function compared with baseline); group 2, temporary worsening (worsening > 10% at day 1 or 2, then complete recovery within 10% of baseline at day 3); and group 3, persistent worsening (>10% decrease compared with baseline). OUTCOMES & MEASUREMENTS: All-cause mortality. RESULTS: 30-day mortality rates were 1.3%, 5.0%, and 12.6% in groups 1 to 3, respectively. Adjusted for baseline characteristics and postoperative complications, 30-day mortality was the greatest in patients with persistent worsening of renal function (hazard ratio [HR], 7.3; 95% confidence interval [CI], 2.7 to 19.8), followed by those with temporary worsening (HR, 3.7; 95% CI, 1.4 to 9.9). During 6.0 +/- 3.4 years of follow-up, 348 patients (36.5%) died. Risk of late mortality was 1.7 (95% CI, 1.3 to 2.3) in the persistent-worsening group followed by those with temporary worsening (HR, 1.5; 95% CI, 1.2 to 1.4). LIMITATIONS: No steady state was achieved to assess renal function. CONCLUSION: Although renal function may recover completely after aortic surgery, temporary worsening of renal function was associated with greater long-term mortality.

Type-D personality and depressive symptoms predict anxiety 12 months post-percutaneous coronary intervention.

BACKGROUND: We examined whether type-D personality exerts a stable effect on anxiety over time and the clinical relevance of type-D personality as a predictor of anxiety 12 months post-percutaneous coronary intervention (PCI). METHODS: Consecutive patients (n=416) with stable or unstable angina pectoris treated with PCI completed the Type-D Scale (DS14) at baseline and the Hospital Anxiety and Depression Scale (HADS) at baseline and 12 months. RESULTS: At baseline, 26% of the patients were anxious, with 67% of these patients still being anxious 12 months post-PCI (p<0.001). There was no significant change in anxiety between baseline and 12 months (p=0.96) nor was the interaction effect type-D personality by time significant (p=0.41). However, type-D patients experienced significantly higher levels of anxiety than non-type-D patients (p<0.001). Type-D personality (OR: 2.89; CI: 1.57-5.34), depressive symptoms (OR: 3.27; CI: 1.73-6.18) and anxiety at baseline (OR: 8.38; CI: 4.65-15.12) were independent predictors of anxiety 12 months post-PCI, adjusting for baseline demographic and clinical characteristics. LIMITATIONS: A limitation of the study is the attrition rate of 105 patients who did not complete the HADS at 12 months. No information was available on the use of psychotropic medication and participation in cardiac rehabilitation, which could serve as confounders. CONCLUSION: Type-D exerted a stable effect on anxiety over time and was an independent predictor of anxiety 12 months post-PCI together with depressive symptoms and anxiety at baseline. The DS14 could be used as a screening tool in clinical practice to identify high-risk patients post-PCI.