1. PROPHYLACTIC PERCUTANEOUS CORONARY INTERVENTION BEFORE NONCARDIAC SURGERY.
Schulman-Marcus J, Feldman DN, Rao SV, et al. Characteristics of patients undergoing cardiac catheterization before noncardiac surgery: a report from the National Cardiovascular Data Registry CathPCI Registry. JAMA Intern Med. 2016;176:611–618.
Current American College of Cardiology/American Heart Association guidelines on perioperative evaluation and management of patients undergoing noncardiac surgery recommend that routine coronary revascularization not to be performed before noncardiac surgery (Fleisher et al, Circulation. 2014;130:e278–e333). Yet, this retrospective analysis of the National Cardiac Data Registry CathPCI Registry found that revascularization was recommended in approximately 24% of nearly 200,000 mostly asymptomatic (about 61%) patients undergoing coronary angiography before noncardiac surgery.
Obstructive coronary artery disease was identified in 48% and coronary revascularization was recommended in 48% of these patients. In those undergoing percutaneous coronary intervention, only 1.3% had left main disease, 14% had proximal left anterior descending artery disease, and 20% had 3-vessel disease. These data indicate a discrepancy between practice and recommendation and the need for more specific evidence-based guidelines and congruent clinical practice.
2. PROBLEM WITH PRACTICE GUIDELINES? UTILIZATION OF CARDIOVASCULAR IMAGING OF PATIENTS WITH CHEST PAIN IN EMERGENCY DEPARTMENT.
Blankenship JC, Wiegers SE; Executive Committees of the Society for Cardiovascular Angiography and Interventions; American Society of Echocardiography. Concerns regarding “2015 ACR/ACC/AHA/AATS/ ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS: appropriate utilization of cardiovascular imaging in emergency department patients with chest pain.” J Am Soc Echocardiogr. 2016;29:379–380.
Rybicki FJ, Udelson JE, Peacock WF, et al. ACR/ACC/AHA/AATS/ ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS: appropriate utilization of cardiovascular imaging in emergency department patients with chest pain. J Am Coll Cardiol. 2016;67:853–879.
Musher DM. Should Committees That Write Guidelines and Recommendations Publish Dissenting Opinions? Mayo Clin Proc. 2016;91:634–639.
Jacobson RM. Clinical practice guidelines and recommendations: room for dissent? Mayo Clin Proc. 2016; 91:551–553.
Clinical guidelines are designed to help clinicians provide optimal care; they may also impact payer decisions. Their validity is influenced by the level (quality) of available evidence and the decisions of the writing and rating panels. This has led to the unusual publication of a critique by the Society for Cardiovascular Angiography and Intervention and the Society of Echocardiography (Blankenship et al) of the recent recommendations for appropriate use criteria, endorsed by a number of prominent societies (Rybicki et al), for cardiovascular imaging of patients presenting with chest pain. Blankenship et al suggest that these guidelines can impact patient care adversely by introducing a new rating designation and ignoring in some instances a large body of literature and expert opinion. It is not clear to this reviewer whether these are legitimate differences of opinion or a signal of deficiency in these new appropriate use criteria. It does emphasize that all guidelines, even those propagated by well-respected societies, need to be scrutinized carefully and viewed with some skepticism.
In a somewhat-related paper and editorial by Musher and Jacobson, respectively, one can read an informative debate as to whether committees that write guidelines should publish dissenting opinions.
3. OPIOID DOSE AND RISK OF SUICIDE.
Ilgen MA, Bohnert AS, Ganoczy D, et al. Opioid dose and risk of suicide. Pain. 2016;157:1079–1084.
Previous studies have observed chronic noncancer pain to be associated with an increased risk of suicide. In this study of 123,946 Veterans Health Affairs patients with chronic noncancer patients who were receiving opioids, the authors observed an association with increasing morphine equivalent daily opioid doses >19 mg/day and suicide risk. Compared with ≤19 mg/day, the hazard ratio with 20 to 50 mg/day was 1.5, with 50 to 100 mg/day was 1.7, and with >100 mg/day was 2.15. The cause of this relationship is unknown (only 15% of these suicides were because of intentional overdose) and requires investigation. These findings, however, suggest that clinicians must view high opioid dosage as a marker of increased risk for suicide in chronic pain patients.
4. IS MEDICAL ERROR THE THIRD LEADING CAUSE OF DEATH IN THE UNITED STATES?
Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.
The list of the most common causes of death in the United States by the Centers for Disease Control and Prevention is based on death certificates, which do not include identification of death due to medical error. On the basis of 4 studies identifying deaths from preventable medical error between 2000 and 2008, these authors extrapolated the number of preventable deaths from medical errors in hospitalized patients in 2013 to be 251,454, making medical error the third leading cause of death, after heart disease (611,000) and cancer (585,000). The authors called for collection of more accurate data on this incidence, which could then be used to assess the effectiveness of methods to reduce these errors.
5. ANESTHESIA EXPOSURE AND RISK OF DEMENTIA
Aiello Bowles EJ, Larson EB, Pong RP, et al. Anesthesia exposure and risk of dementia and Alzheimer’s disease: a prospective study. J Am Geriatr Soc. 2016;64:602–607.
On the basis of preclinical studies and conflicting observational clinical studies, there remains concern that anesthesia exposure may increase the risk of dementia and Alzheimer disease (AD). In this prospective study of 3988 patients ≥65 years of age and free of dementia at baseline who underwent biannual evaluation for a mean of 7 years, 24% developed dementia, including 19% with AD. Exposure (by self-reporting) to high-risk surgery with general anesthesia (GA), low-risk surgery with GA, and surgery with regional anesthesia, whether ever or within the past 5 years, was not associated with an increased risk of developing dementia or AD, nor was there a relationship with the number of surgeries under GA. These data are reassuring, but limited by being observational and relying on self-reporting of anesthesia exposure.
6. READMISSION AFTER TOTAL HIP REPLACEMENT
Siracuse BL, Chamberlain RS. A preoperative scale for determining surgical readmission risk after total hip replacement. JAMA Surg. 2016. doi: 10.1001/ jamasurg.2016.0020. [Epub ahead of print].
Kapoor A, Chew PW, Reisman JI, Berlowitz DR. Low self-reported function predicts adverse postoperative course in veterans affairs beneficiaries undergoing total hip and total knee replacement. J Am Geriatr Soc. 2016;64:862–869.
Readmission is an important metric in assessing quality of care, and the Perioperative Surgical Home model suggests that anesthesiologists can/should play a role in minimizing hospital readmissions. Total hip replacement is one of the most common orthopedic procedures. On the basis of discharge data from >250,000 patients, Siracuse et al developed a Readmission After Total Hip Replacement Risk score to predict readmissions. When applied to a validated cohort of >150,000 patients, this score explained 89% of readmission variability (average readmission rate of 5.8%). On the basis of (a) the use of the Readmission After Total Hip Replacement Risk score, (b) the causes of readmission reported here, and (c) the factors associated with readmission, the perioperative team may be able to identify patients at greater risk of readmission and develop an individual perioperative care plan for these patients to reduce this risk.
In an observational study of male veterans ≥65 years of age undergoing total hip replacement or total knee replacement, Kapoor et al found that adding low self-reported physical and/or mental function to the American College of Surgeons Universal Risk Calculator was associated with nearly twice the risk of readmission and of serious complications.
7. TRANSCATHETER AORTIC VALVE REPLACEMENT. CHANGING FACE OF CARDIAC ANESTHESIA?
Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374:1609–1620.
Thourani VH, Kodali S, Makkar RR, et al. Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis. Lancet. 2016;387:2218–2225.
Kodali S, Williams MR, Doshi D, et al. Sex-specific differences at presentation and outcomes among patients undergoing transcatheter aortic valve replacement: a cohort study. Ann Intern Med. 2016;164:377–384.
Kiramijyan S, Ben-Dor I, Koifman E, et al. Comparison of clinical outcomes with the utilization of monitored anesthesia care vs. general anesthesia in patients undergoing transcatheter aortic valve replacement. Cardiovasc Revasc Med. 2016.
The management of very high risk (for open surgery) patients with aortic stenosis is rapidly moving to transcatheter aortic valve replacement (TAVR), which is affecting the practice of cardiac anesthesia. Leon et al reported the results of the multicenter Placement of Aortic Transcatheter Valves (PARTNER) 2 cohort randomized trial of patients at “intermediate risk” for surgery (4%–8% risk of death) for symptomatic severe aortic stenosis, comparing TAVR with open surgical valve replacement. There was no observed difference in death or stroke at 2 years, but there was less life-threatening bleeding, acute kidney injury, new-onset atrial fibrillation, and shorter length of stay in those undergoing TAVR. In the subset who received transfemoral access for TAVR (76%), the combined end point of death or stroke was lower in the TAVR patients. The accompanying editorial by Moat (NEJM. 2016; 374:1682–1683) opined that these findings suggest that TAVR is the treatment of choice for intermediate-risk patients if they can undergo a transfemoral approach. Thourani et al also found, using propensity score matching, an improved composite outcome (death, stroke, and moderate-to-severe aortic regurgitation) at 1 year in patients undergoing transfemoral TAVR in the SAPIEN 3 study as compared with that in surgery in the PARTNER 2A trial in intermediate risk patients.
Interestingly, in an analysis of the PARTNER trials comparing 1220 women with 1339 men, Kodali et al found that although the incidence of major bleeding and vascular complications was greater in women, all-cause mortality at 1 year was lower in women (19% vs 26%). This result is the opposite of findings with surgical aortic valve replacement.
Although less so in Europe, most TAVRs in the United States, at least until recently, were performed with the patient under general anesthesia (GA). Kiramijyan et al compared their large experience using monitored anesthesia care (MAC) with local anesthesia (their preferred approach) in 466 patients undergoing transfemoral TAVR compared with GA in 66 patients. They reviewed their exclusion criteria for MAC and found MAC to be feasible, safe and compatible with transesophageal echocardiography (in 78% of cases) and to be associated with shorter hospital stay. They also described in detail the reasons for conversion to GA in 56 (12%) of their MAC patients.
8. DEXMEDETOMIDINE TO MANAGE AGITATED DELIRIUM IN THE INTENSIVE CARE UNIT
Reade MC, Eastwood GM, Bellomo R, et al. Effect of dexmedetomidine added to standard care on ventilator-free time in patients with agitated delirium: a randomized clinical trial. JAMA. 2016;315:1460–1468.
Agitated depression is common in critically ill patients and associated with increased morbidity and mortality. In this randomized multicenter study of 74 adult intensive care unit patients with agitated depression preventing extubation, the investigators compared infusions of dexmedetomidine for up to 7 days versus placebo. Patients receiving dexmedetomidine had increased ventilator free hours, reduced time to extubation, and accelerated resolution of delirium. If confirmed by larger studies, this offers an important approach for the management of agitated delirium in the intensive care unit.
RECENT REVIEW PAPERS
Executive Section Editor’s Note: Beginning with this issue, we will also be calling attention to a number of recent review papers that may be of interest to anesthesiologists and the readership of Anesthesia & Analgesia.
- Schulman-Marcus J, Pashun RA, Feldman DN, Swaminathan RV. Coronary angiography and revascularization prior to noncardiac surgery. Curr Treat Options Cardiovasc Med. 2016;18:3.
- Bonow RO, Leon MB, Doshi D, Moat N. Management strategies and future challenges for aortic valve disease. Lancet. 2016;387:1312–1323.
- Mol BW, Roberts CT, Thangaratinam S, et al. Pre-eclampsia. Lancet. 2016;387:999–1011.
- Arany Z, Elkayam U. Peripartum cardiomyopathy. Circulation. 2016;133:1397–1409.
- Subramaniam RM, Suarez-Cuervo C, Wilson RF, et al. Effectiveness of prevention strategies for contrast-induced nephropathy: a systematic review and meta-analysis. Ann Intern Med. 2016;164:406–416.
- Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2016;29:277–314.
- Bertrand PB, Levine RA, Isselbacher EM, Vandervoort PM. Fact or artifact in two-dimensional echocardiography: avoiding misdiagnosis and missed diagnosis. J Am Soc Echocardiogr. 2016;29:381–391.
- Petersen LR, Jamieson DJ, Powers AM, Honein MA. Zika virus. N Engl J Med. 2016; 374:1552–1563.
- Broutet N, Krauer F, Riesen M, et al. Zika virus as a cause of neurologic disorders. N Engl J Med. 2016;374:1506–1509.