vicky3 2009-11-4 16:43
Statins類藥物可以減少主動脈手術的費用及併發症
作者：Kathleen Louden
出處：WebMD醫學新聞
October 20, 2009（伊利諾州芝加哥訊）－一項新研究顯示，在選擇性修補腹主動脈手術之前進行Statins類藥物療法，顯然可以降低與術式有關之發病率、死亡率及費用，不論這項術式是屬於開腹、還是血管內的。
這些發現提供了支持2007年美國心臟醫學會/美國心臟學會（AHA/ACC）非心臟手術術前心臟血管評估指引（Circulation. 2007;116:1971-1996）的證據。這些指引宣稱術前使用Statins類藥物對於接受血管手術病患來說是合理的，且如果病患已經在服用Statins類藥物，則應該繼續使用。
主要作者、北卡羅萊納州Greenville東卡羅萊納大學東卡羅萊納心臟機構的第三年一般外科住院醫師Michael McNally表示，Statins類藥物治療對於降低接受血管手術病患風險來說是個關鍵，特別是主動脈手術。他聲稱，Statins類藥物不僅僅是降低血脂肪而已。
【風險最佳化的影響】
McNally醫師於美國外科醫學會第95屆年會上發表研究結果。這項研究的主要目的在於確定接受腹主動脈瘤修補手術病患心臟血管風險最佳化所帶來的臨床與經濟上的影響。
根據這篇摘要，在2004年到2007年之間，總共181位病患接受選擇性動脈瘤修補手術，這些病患在術前開始使用Statins類藥物，另外216位沒有使用Statins類藥物的病患作為控制組。
MCnALLY醫師表示，使用Statins類藥物的病患族群，其術前血管手術學會（SVS）共病風險分數較高，代表他們病得比較嚴重。然而，這些病患被預期發生術後併發症的機率低於控制組（分別是11.1%與4.4%；P=0.01）。量測的併發症包括心肌梗塞、中風、腎衰竭、出血、肺炎、尿道感染與傷口感染。
作者們在摘要中寫到，Statins類藥物組病患，沒有人在術後30天內死亡，控制組病患則有5%死亡（P<0.01達到統計上顯著差異）。Statins類藥物治療轉換成經濟效益為血管內手術病患每人可省下3,205美元，開腹修補病患可省下3793美元。
McNally醫師在新聞稿中表示，其團隊觀察到，手術後的頭30天，使用Statins類藥物就有好處。
【結果改變臨床執業】
McNally醫師表示，這項研究結果確實改變我們醫院的執業方式。他解釋外科醫師們將會開立Statins類藥物給還沒有使用這些藥物的轉介病患，延遲動脈瘤修復手術，並通知轉介醫師。
他向Medscape一般外科表示，外科醫師應該評估他們是否遵循AHA/ACC指引，如果沒有的話，開始適當治療。
然而，新罕布夏Lebanon Dartmouth-Hitchcock醫學中心的一位血管外科醫師Phillip Goodney向Medscape一般外科表示，由於這是一項觀察性、非隨機分派研究設計，很難以目前的數據做出Statins類治療應該作為接受血管手術病患初級預防心臟血管併發症的結論。
Goodney醫師是這項發表會的討論者，但是並未參與這項研究。他在訪談中表示，我認為目前這項研究再次強化了較大病患系列研究與臨床試驗已經確認Statins類藥物治療用於許多不同血管術式的好處。
McNally醫師與Goodney醫師表示已無相關資金上的往來。
Statin Drugs Lower Costs and Complications of Aortic Surgery
By Kathleen Louden
Medscape Medical News
October 20, 2009 (Chicago, Illinois) — Statin therapy administered before elective surgery to repair abdominal aortic aneurysm appears to decrease the morbidity, mortality, and cost of the procedure, regardless of whether the repair is open or endovascular, a new study shows.
The findings add to the evidence supporting the 2007 American Heart Association/American College of Cardiology (AHA/ACC) Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery (Circulation. 2007;116:1971-1996). These guidelines state that perioperative statin use is reasonable for patients undergoing vascular surgery and should be continued if the patient is already taking a statin.
"Statin therapy is the cornerstone of risk reduction in patients undergoing vascular surgery, especially aortic surgery," said the lead author Michael McNally, MD, a third-year general surgery resident at the East Carolina Heart Institute at East Carolina University in Greenville, North Carolina. "Statins are definitely not just cholesterol-lowering agents," he asserted.
Impact of Risk Optimization
Dr. McNally presented the results here at the American College of Surgeons 95th Annual Clinical Congress. The aim of the study was to determine the clinical and economic impact of cardiovascular risk optimization in patients undergoing repair of an aortic aneurysm.
A total of 181 patients who had elective aneurysm repair between 2004 and 2007 received statin medications preoperatively and 216 did not (control group), according to the abstract.
The statin cohort had a higher Society for Vascular Surgery (SVS) comorbidity risk score before surgery, indicating they were sicker, Dr. McNally said. However, these patients experienced significantly fewer postoperative complications than the control subjects (11.1% vs 4.4%, respectively; P?= .01). Complications measured included myocardial infarction, stroke, renal failure, bleeding, pneumonia, urinary tract infection, and wound infection.
No patients in the statin cohort died in the first 30?days after surgery, but 5% of control subjects did (a significant difference; P?< .01), the authors write in their abstract. Statin therapy translated to a hospital cost savings per patient of $3205 for endovascular repair and $3793 for open repair.
Dr. McNally reported in a press release that his team observed the significant benefit of statin therapy after only 30?days of treatment.
Results Changed Clinical Practice
"This [study result] has actually changed the practice pattern at our hospital," Dr. McNally said. He explained that the surgeons will prescribe a statin for referral patients who are not already receiving the medication, postpone the aneurysm repair, and inform the referring physician.
He told Medscape General Surgery that surgeons should evaluate whether they are adhering to the AHA/ACC guidelines and initiate appropriate therapy if they are not.
However, Philip Goodney, MD, a vascular surgeon at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, told Medscape General Surgery that, "given the observational, nonrandomized nature of this report, it is difficult to conclude from the data at hand that statin therapy should be mandated for primary prevention of cardiovascular complications in patients undergoing vascular surgery."
Dr. Goodney was the discussant for this presentation but did not participate in the study. "I think that the current study reinforces larger series and trials that have confirmed the overall benefits of statin therapy in a broad range of vascular procedures," he said during the interview.
Dr. McNally and Dr. Goodney have disclosed no relevant financial relationships.
American College of Surgeons (ACS) 95th Annual Clinical Congress: Surgical Forum. Presented October 15, 2009.