title: Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial Haemostatic Factors and the Risk of Cardiovascular Death in Patients With Coronary Artery Disease: The AtheroGene Study Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control? Which Hemostatic Markers Add to the Predictive Value of Conventional Risk Factors for Coronary Heart Disease and Ischemic Stroke?: The Caerphilly Study Selective &bgr;1-Antagonism with Bisoprolol Is Associated with Fewer Postoperative Strokes than Atenolol or Metoprolol: A Single-center Cohort Study of 44,092 Consecutive Patients Bisoprolol reduces cardiac death and myocardial infarction in high-risk patients as long as 2 years after successful major vascular surgery. Patients with Stable Coronary Artery Disease Receiving Chronic Statin Treatment Who Are Undergoing Noncardiac Emergency Surgery Benefit from Acute Atorvastatin Reload Randomized clinical trial of screening for abdominal aortic aneurysm in women Cardiovascular predictors for long-term mortality after EVAR for AAA Early and late outcome of surgical repair for small abdominal aortic aneurysms: a population-based analysis. A randomised study of perioperative esmolol infusion for haemodynamic stability during major vascular surgery; rationale and design of DECREASE-XIII. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. Angiotensin-converting enzyme inhibitors and aortic rupture: a population-based case-control study Thrombus volume is associated with cardiovascular events and aneurysm growth in patients who have abdominal aortic aneurysms. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK Small Aneurysm Trial Participants. Rationale, design, and organization of the PeriOperative ISchemic Evaluation (POISE) trial: a randomized controlled trial of metoprolol versus placebo in patients undergoing noncardiac surgery. The fate of patients undergoing surveillance of small abdominal aortic aneurysms. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. Effects of Rosuvastatin With or Without Ezetimibe on Clinical Outcomes in Patients Undergoing Elective Vascular Surgery Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial Preoperative Rosuvastatin Protects Patients with Coronary Artery Disease Undergoing Noncardiac Surgery Inhibition of inflammation mediates the protective effect of atorvastatin reload in patients with coronary artery disease undergoing noncardiac emergency surgery Perioperative myocardial ischemic injury in high-risk vascular surgery patients: incidence and clinical significance in a prospective clinical trial. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. The effect of beta-blocker dosing strategy on regulation of perioperative heart rate and clinical outcomes in patients undergoing vascular surgery: a randomized comparison. STAR VaS - Short Term Atorvastatin Regime for Vasculopathic Subjects: a randomized placebo-controlled trial evaluating perioperative atorvastatin therapy in noncardiac surgery The Effect of Adding Ezetimibe to Rosuvastatin on Renal Function in Patients Undergoing Elective Vascular Surgery The Role of Smoking in Abdominal Aortic Aneurysm Development Fluvastatin and perioperative events in patients undergoing vascular surgery. Statin therapy is associated with improved survival after endovascular and open aneurysm repair.
abstract: BACKGROUND Trials of beta blockers in patients undergoing non-cardiac surgery have reported conflicting results . This r and omised controlled trial , done in 190 hospitals in 23 countries , was design ed to investigate the effects of perioperative beta blockers . METHODS We r and omly assigned 8351 patients with , or at risk of , atherosclerotic disease who were undergoing non-cardiac surgery to receive extended-release metoprolol succinate ( n=4174 ) or placebo ( n=4177 ) , by a computerised r and omisation phone service . Study treatment was started 2 - 4 h before surgery and continued for 30 days . Patients , health-care providers , data collectors , and outcome adjudicators were masked to treatment allocation . The primary endpoint was a composite of cardiovascular death , non-fatal myocardial infa rct ion , and non-fatal cardiac arrest . Analyses were by intention to treat . This trial is registered with Clinical Trials.gov , number NCT00182039 . FINDINGS All 8351 patients were included in analyses ; 8331 ( 99.8 % ) patients completed the 30-day follow-up . Fewer patients in the metoprolol group than in the placebo group reached the primary endpoint ( 244 [ 5.8 % ] patients in the metoprolol group vs 290 [ 6.9 % ] in the placebo group ; hazard ratio 0.84 , 95 % CI 0.70 - 0.99 ; p=0.0399 ) . Fewer patients in the metoprolol group than in the placebo group had a myocardial infa rct ion ( 176 [ 4.2 % ] vs 239 [ 5.7 % ] patients ; 0.73 , 0.60 - 0.89 ; p=0.0017 ) . However , there were more deaths in the metoprolol group than in the placebo group ( 129 [ 3.1 % ] vs 97 [ 2.3 % ] patients ; 1.33 , 1.03 - 1.74 ; p=0.0317 ) . More patients in the metoprolol group than in the placebo group had a stroke ( 41 [ 1.0 % ] vs 19 [ 0.5 % ] patients ; 2.17 , 1.26 - 3.74 ; p=0.0053 ) . INTERPRETATION Our results highlight the risk in assuming a perioperative beta-blocker regimen has benefit without substantial harm , and the importance and need for large r and omised trials in the perioperative setting . Patients are unlikely to accept the risks associated with perioperative extended-release metoprolol Objective —To get a better insight into the role of hemostasis in coronary artery disease ( CAD ) , we assessed the impact of von Willebr and factor ( vWF ) , fibrinogen , thrombin-antithrombin ( TAT ) complexes , D-dimers , and plasmin-antiplasmin ( PAP ) complexes on the risk of cardiovascular event in a prospect i ve cohort of CAD patients . Methods and Results —The prospect i ve Atherogene cohort includes 1057 individuals with an angiographically proven coronary artery disease at baseline . After a median follow-up of 6.6 years , 135 individuals died from a cardiovascular cause and 97 had a nonfatal cardiovascular event . Higher levels of all 5 hemostatic markers at baseline were associated with an increased risk of cardiovascular death , but not of nonfatal event . Except for vWF , these associations remained significant after adjustment for conventional cardiovascular risk factors and C-reactive protein ( CRP ) levels ( P for trend according to increasing tertiles=0.20 , 0.011 , 0.026 , 0.019 , and 0.01 for vWF , fibrinogen , TAT , D-Dimer , and PAP , respectively ) . When including the 5 hemostatic markers in a stepwise Cox regression analysis where conventional risk factors and CRP were forced into the model , fibrinogen and D-dimers remained independently associated with the risk of cardiovascular death . Adjusted hazard ratios ( 95 % CI ) associated with one SD increase of fibrinogen and D-dimers were 1.27 ( 1.04 to 1.55 ) and 1.29 ( 1.09 to 1.53 ) , respectively . Conclusions —In patients with coronary artery disease , fibrinogen and D-dimer levels are independent predictors of subsequent cardiovascular death . Our data support a role of impaired coagulation/fibrinolysis process in the complications of coronary artery disease OBJECTIVES The purpose of this study was to assess the value of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate ( HR ) control scheduled for major vascular surgery . BACKGROUND Treatment guidelines of the American College of Cardiology/American Heart Association recommend cardiac testing in these patients to identify subjects at increased risk . This policy delays surgery , even though test results might be redundant and beta-blockers with tight HR control provide sufficient myocardial protection . Furthermore , the benefit of revascularization in high-risk patients is ill-defined . METHODS All 1,476 screened patients were stratified into low-risk ( 0 risk factors ) , intermediate-risk ( 1 to 2 risk factors ) , and high-risk ( > or =3 risk factors ) . All patients received beta-blockers . The 770 intermediate-risk patients were r and omly assigned to cardiac stress-testing ( n = 386 ) or no testing . Test results influenced management . In patients with ischemia , physicians aim ed to control HR below the ischemic threshold . Those with extensive stress-induced ischemia were considered for revascularization . The primary end point was cardiac death or myocardial infa rct ion at 30-days after surgery . RESULTS Testing showed no ischemia in 287 patients ( 74 % ) ; limited ischemia in 65 patients ( 17 % ) , and extensive ischemia in 34 patients ( 8.8 % ) . Of 34 patients with extensive ischemia , revascularization before surgery was feasible in 12 patients ( 35 % ) . Patients assigned to no testing had similar incidence of the primary end point as those assigned to testing ( 1.8 % vs. 2.3 % ; odds ratio [ OR ] 0.78 ; 95 % confidence interval [ CI ] 0.28 to 2.1 ; p = 0.62 ) . The strategy of no testing brought surgery almost 3 weeks forward . Regardless of allocated strategy , patients with a HR < 65 beats/min had lower risk than the remaining patients ( 1.3 % vs. 5.2 % ; OR 0.24 ; 95 % CI 0.09 to 0.66 ; p = 0.003 ) . CONCLUSIONS Cardiac testing can safely be omitted in intermediate-risk patients , provided that beta-blockers aim ing at tight HR control are prescribed Background — Few studies have examined whether hemostatic markers contribute to risk of coronary disease and ischemic stroke independently of conventional risk factors . This study examines 11 hemostatic markers that reflect different aspects of the coagulation process to determine which have prognostic value after accounting for conventional risk factors . Methods and Results — A total of 2398 men aged 49 to 65 years were examined in 1984 to 1988 , and the majority gave a fasting blood sample for assay of lipids and hemostatic markers . Men were followed up for a median of 13 years , and cardiovascular disease ( CVD ) events were recorded . There were 486 CVD events in total , 353 with prospect i ve coronary disease and 133 with prospect i ve ischemic stroke . On univariable analysis , fibrinogen , low activated protein C ratio , D-dimer , tissue plasminogen activator ( tPA ) , and plasminogen activator inhibitor-1 ( PAI-1 ) were associated significantly with risk of CVD . On multivariable analyses with conventional risk factors forced into the proportional hazards model , fibrinogen , D-dimer , and PAI-1 were significantly associated with risk of CVD , whereas factor VIIc showed an inverse association ( P=0.001 ) . In a model that contained the conventional risk factors , the hazard ratio for subsequent CVD in the top third of the distribution of predicted risk relative to the bottom third was 2.7 for subjects without preexisting CVD . This ratio increased to 3.7 for the model that also contained the 4 hemostatic factors . Conclusions — Fibrinogen , D-dimer , PAI-1 activity , and factor VIIc each has potential to increase the prediction of coronary disease/ischemic stroke in middle-aged men , in addition to conventional risk factors Background : Perioperative metoprolol increases  postoperative stroke .  Animal studies indicate that the mechanism may be related to attenuated & bgr;2-adrenoreceptor-mediated cerebral vasodilatation . The authors therefore conducted a cohort to study whether the highly & bgr;1-specific & bgr;-blocker ( bisoprolol ) was associated with a reduced risk of postoperative stroke compared with less selective & bgr;-blockers ( metoprolol or atenolol ) . Methods : The authors conducted a single-center study on 44,092 consecutive patients with age 50 yr or more having noncardiac , nonneurologic surgery . The primary outcome was stroke within 7 days of surgery . The secondary outcome was a composite of all-cause mortality , postoperative myocardial injury , and stroke . A propensity score-matched cohort was created to assess the independent association between bisoprolol and less & bgr;1-selective agents metoprolol or atenolol . A secondary analysis using logistic regression , based on previously identified confounders , also compared selective & bgr;1-antagonism . Results : Twenty-four percent ( 10,756 ) of patients were exposed to in-hospital & bgr;-blockers . A total of 88 patients ( 0.2 % ) suffered a stroke within 7 days of surgery . The matched cohort consisted of 2,462 patients , and the pairs were well matched for all variables . Bisoprolol was associated with fewer postoperative strokes than the less selective agents ( odds ratio = 0.20 ; 95 % CI , 0.04–0.91 ) . Multivariable risk-adjustment in the & bgr;-blockers-exposed patients comparing bisoprolol with the less selective agents was associated with a similarly reduced stroke rate . Conclusions : The use of metoprolol and atenolol is associated with increased risks of postoperative stroke , compared with bisoprolol . These findings warrant confirmation in a pragmatic r and omized trial AIM To assess the long-term cardioprotective effect of bisoprolol in a r and omized high-risk population after successful major vascular surgery . High-risk patients were defined by the presence of one or more cardiac risk factor(s ) and a dobutamine echocardiography test positive for ischaemia . METHODS 1351 patients were screened prior to surgery , 846 patients had one or more risk factor(s ) , and 173 of these patients also had ischaemia during dobutamine echocardiography . One hundred and twelve patients could be r and omized for additional bisoprolol therapy or st and ard care . Eleven patients died in the peri-operative period ( up to 1 month after surgery ) . R and omized patients continued bisoprolol or st and ard care after surgery . During follow-up of 101 survivors ( median 22 months , range 11 - 30 ) cardiac death or myocardial infa rct ion was noted . No patient was lost during follow-up . Results The incidence of cardiac events during follow-up in the bisoprolol group was 12 % vs 32 % in the st and ard care group ( P=0.025 ) . Cardiac death occurred in 15 patients , nine patients in the st and ard care and in six in the bisoprolol group ; myocardial infa rct ion occurred in six patients , five in the st and ard care and one in the bisoprolol group . The odds ratio for cardiac death or myocardial infa rct ion after surgery in high-risk patients with additional bisoprolol therapy was 0.30 ( 0.11 - 0.83 ) . CONCLUSIONS Bisoprolol significantly reduced long-term cardiac death and myocardial infa rct ion in high-risk patients after successful major cardiac vascular surgery Objective : This study was design ed to investigate whether patients with stable coronary artery disease ( CAD ) receiving chronic statin treatment who are undergoing noncardiac emergency surgery benefit from acute atorvastatin reload . Methods : A total of 500 patients with stable CAD and regular administration of statin before noncardiac emergency surgery were r and omized to atorvastatin reload ( n = 250 ) or placebo ( n = 250 ) . All patients received atorvastatin treatment thereafter . The primary end point was a 30-day incidence of major adverse cardiac events ( MACE ) . Secondary end points were the incidence of atrial fibrillation ( AF ) during hospitalization and length of hospital stay . Results : The primary end point occurred in 2.4 % of patients treated with atorvastatin reload and in 8 % in the placebo arm ( p = 0.0088 ) . The incidence of AF during hospitalization was 6.8 % in patients treated with atorvastatin reload and 17 % in the placebo arm ( p = 0.0003 ) . Compared with the placebo arm , the atorvastatin reload arm shortened the length of stay ( 9.8 ± 3.3 vs. 10.6 ± 3.5 days , p = 0.009 ) . Multivariable analysis suggested that atorvastatin reload conferred a 65 % risk reduction of 30-day MACE ( odds ratio 0.35 , 95 % confidence interval 0.18 - 0.86 ; p = 0.005 ) . Conclusion : The trial suggests that atorvastatin reload may improve the clinical outcome of patients with stable CAD receiving chronic statin treatment who are undergoing noncardiac emergency surgery Screening for abdominal aortic aneurysm ( AAA ) is commonly restricted to men . Recent studies have indicated a possible increase in deaths due to ruptured AAA in women , and a higher rate of rupture in women than in men . The present report details results from a r and omized controlled trial that assessed the effects of screening women for AAA The aim of this study was to assess cardiovascular predictors for all-cause long-term mortality in patients undergoing st and ard endovascular aneurysm repair ( EVAR ) for infrarenal abdominal aortic aneurysm ( AAA ) . Consecutive patients treated with EVAR ( Zenith ® stent grafts ; Cook ) between May 1998 and February 2006 were prospect ively enrolled in a computerized data base , together with retrospectively collected data on medication , and electrocardiographic and echocardiographic variables . Mortality was assessed on 1 December 2010 . The median follow-up time was 68 months and the median age was 74 years ( range 53–89 ) for the 304 patients . Mortality at the end of follow-up was 54.3 % ( 165/304 ) . The proportion of deaths caused by vascular diseases was 61 % ( 101/165 ) . In the univariate analysis , low preoperative ejection fraction ( EF ) ( p = 0.004 ) , absence of statin medication ( p = 0.007 ) , and medication with diuretics ( p = 0.028 ) or digitalis ( p = 0.016 ) were associated with an increased long-term mortality rate . Myocardial ischemia on electrocardiogram ( ECG ) ( hazard ratio ( HR ) 1.6 [ 95 % CI 1.1–2.4 ] ) and anemia ( HR 1.5 [ 95 % CI 1.0–2.1 ] ) were found to be independent predictors for long-term mortality after Cox regression analysis . There was a trend that chronic kidney disease , stage ≥ 3 ( HR 1.5 [ 95 % CI 1.0–2.2 ] ) , and age 80 years and above ( HR 1.5 [ 95 % CI 1.0–2.4 ] ) were independently associated with long-term mortality . In conclusion , ischemia on ECG and anemia were independently related to an increased long-term mortality rate after EVAR , and these predictive factors seem to be most important for critical assessment in the preoperative medical work-up PURPOSE Whether small abdominal aortic aneurysms ( AAAs ) ( < or = 5 cm in diameter ) should be repaired early to enhance late survival remains controversial . Long-term population -based data on the surgical outcome for small AAAs may help to establish practice guidelines until r and omized clinical trials are completed . METHODS To examine an entire community experience with small AAAs , we conducted a population -based analysis of the recognition , reasons for operation , perioperative mortality rates , and late survival  in Olmsted County , Minnesota . RESULTS The incidence of recognized small AAAs increased thirtyfold during a 30-year period . The propensity to repair small AAAs also increased during the same period . Eventually one third of small AAAs were repaired . The primary reasons for surgical consultation and operation were presence of the aneurysm ( 49 % ) , expansion on serial examination ( 28 % ) , nonspecific abdominal or back symptoms ( 18 % ) , and excessive patient anxiety about the aneurysm ( 5 % ) . Community operative mortality rates for small AAAs were low ( 2.6 % ) compared with those for large aneurysms ( 5.5 % ) ( p = 0.65 ) . However , the observed 5-year survival rate for the group undergoing repair of small aneurysms was 62 % , which was significantly less than the 83 % expected survival for the general population ( p < 0.05 ) . Relative survival for the operated small and large aneurysms was similar . The primary cause of death for both groups was myocardial infa rct ion . CONCLUSIONS The results of our population -based analysis indicate that early operative results for elective repair of small AAAs are excellent , but late survival remains significantly impaired by coronary heart disease . Consequently , our data question whether early repair of small AAAs will enhance late survival . Until r and omized clinical trials on management of small AAAs are completed , most small AAAs should be monitored for expansion and operated on electively when they approach or enter the range of 5 to 6 cm in good-risk patients OBJECTIVES This article describes the rationale and design of the DECREASE-XIII trial , which aims to evaluate the potential of esmolol infusion , an ultra-short-acting beta-blocker , during surgery as an add-on to chronic low-dose beta-blocker therapy to maintain perioperative haemodynamic stability during major vascular surgery . DESIGN A double-blind , placebo-controlled , r and omised trial . MATERIAL S & METHODS A total of 260 vascular surgery patients will be r and omised to esmolol or placebo  as an add-on to st and ard medical care , including chronic low-dose beta-blockers . Esmolol is titrated to maintain a heart rate within a target window of 60 - 80 beats per minute for 24 h from the induction of anaesthesia . Heart rate and ischaemia are assessed by continuous 12-lead electrocardiographic monitoring for 72 h , starting 1 day prior to surgery . The primary outcome measure is duration of heart rate outside the target window during infusion of the study drug . Secondary outcome measures will be the efficacy parameters of occurrence of cardiac ischaemia , troponin T release , myocardial infa rct ion and cardiac death within 30 days after surgery and safety parameters such as the occurrence of stroke and hypotension . CONCLUSIONS This study will provide data on the efficacy of esmolol titration in chronic beta-blocker users for tight heart-rate control and reduction of ischaemia in patients undergoing vascular surgery as well as data on safety parameters BACKGROUND Although the initial results of endovascular repair of abdominal aortic aneurysms were promising , current evidence from controlled studies does not convincingly show a reduction in 30-day mortality relative to that achieved with open repair . METHODS We conducted a multicenter , r and omized trial comparing open repair with endovascular repair in 345 patients who had received a diagnosis of abdominal aortic aneurysm of at least 5 cm in diameter and who were considered suitable c and i date s for both techniques . The outcome events analyzed were operative ( 30-day ) mortality and two composite end points of operative mortality and severe complications and operative mortality and moderate or severe complications . RESULTS The operative mortality rate was 4.6 percent in the open-repair group ( 8 of 174 patients ; 95 percent confidence interval , 2.0 to 8.9 percent ) and 1.2 percent in the endovascular-repair group ( 2 of 171 patients ; 95 percent confidence interval , 0.1 to 4.2 percent ) , result ing in a risk ratio of 3.9 ( 95 percent confidence interval , 0.9 to 32.9 ) . The combined rate of operative mortality and severe complications was 9.8 percent in the open-repair group ( 17 of 174 patients ; 95 percent confidence interval , 5.8 to 15.2 percent ) and 4.7 percent in the endovascular-repair group ( 8 of 171 patients ; 95 percent confidence interval , 2.0 to 9.0 percent ) , result ing in a risk ratio of 2.1 ( 95 percent confidence interval , 0.9 to 5.4 ) . CONCLUSIONS On the basis of the overall results of this trial , endovascular repair is preferable to open repair in patients who have an abdominal aortic aneurysm that is at least 5 cm in diameter . Long-term follow-up is needed to determine whether this advantage is sustained BACKGROUND Angiotensin-converting enzyme ( ACE ) inhibitors prevent the expansion and rupture of aortic aneurysms in animals . We investigated the association between ACE inhibitors and rupture in patients with abdominal aortic aneurysms . METHODS We did a population -based case-control study of linked administrative data bases in Ontario , Canada . The sample included consecutive patients older than 65 ( n=15,326 ) admitted to hospital with a primary diagnosis of ruptured or intact abdominal aortic aneurysm between April 1 , 1992 , and April 1 , 2002 . FINDINGS Patients who received ACE inhibitors before admission were significantly less likely to present with ruptured aneurysm ( odds ratio [ OR ] 0.82 , 95 % CI 0.74 - 0.90 ) than those who did not receive ACE inhibitors . Adjustment for demographic characteristics , risk factors for rupture , comorbidities , contraindications to ACE inhibitors , measures of health-care use , and aneurysm screening yielded similar results ( 0.83 , 0.73 - 0.95 ) . Consistent findings were noted in subgroups at high risk of rupture , including patients older than 75 years and those with a history of hypertension . Conversely , such protective associations were not observed for beta blockers ( 1.02 , 0.89 - 1.17 ) , calcium channel blockers ( 1.01 , 0.89 - 1.14 ) , alpha blockers ( 1.15 , 0.86 - 1.54 ) , angiotensin receptor blockers ( 1.24 , 0.71 - 2.18 ) , or thiazide diuretics ( 0.91 , 0.78 - 1.07 ) . INTERPRETATION ACE inhibitors are associated with a reduced risk of ruptured abdominal aortic aneurysm , unlike other antihypertensive agents . R and omised trials of ACE inhibitors for prevention of aortic rupture might be warranted BACKGROUND Patients with abdominal aortic aneurysms ( AAA ) are predisposed to cardiovascular events and often experience continual expansion of their aneurysm . Cardiovascular events and expansion rates are positively correlated with aneurysm size . AAA is usually associated with intraluminal thrombus , which has previously been implicated in AAA pathogenesis . This study prospect ively assessed the association of infrarenal abdominal aortic thrombus volume with cardiovascular events and AAA growth . METHODS Ninety-eight patients with AAAs underwent computed tomography angiography ( CTA ) .  The volume of infrarenal aorta thrombus was measured by a previously vali date d technique . Patients were monitored prospect ively for a median of 3 years ( interquartile range [ IQR ] , 2.0 - 3.6 years ) , and cardiovascular events ( nonfatal stroke , nonfatal myocardial infa rct ion , coronary revascularization , amputation , and cardiovascular death ) were recorded . Of the original patients , 39 underwent repeat CTA a median of 1.5 years ( IQR , 1.1 - 3.3 years ) after entry to the study . Kaplan-Meier and Cox proportional analysis were used to examine the association of aortic thrombus with cardiovascular events and average weighted AAA growth . RESULTS There were 28 cardiovascular events during follow-up . The incidence of cardiovascular events was 23.4 % and 49.2 % for patients with small ( smaller than the median ) and large ( median or larger ) volumes of aortic thrombus , respectively , at 4 years ( P = .040 ) . AAA thrombus volume of median or larger was associated with increased cardiovascular events ( relative risk [ RR ] 2.8 , 95 % confidence interval [ CI ] , 1.01 - 5.24 ) independent of other risk factors , including initial AAA diameter , but was only of borderline significance when patients were censored at the time of AAA repair ( RR , 2.35 ; 95 % CI , 0.98 - 5.63 ) . In the subset of patients with CTA follow-up , the median annual increase in AAA volume was 5.1 cm³ ( IQR , 0.8 - 10.3 cm³ ) . Annual AAA volume increase was positively correlated with initial AAA diameter ( r = 0.44 , P = .006 ) and thrombus volume ( r = 0.50 , P = .001 ) . Median or larger aortic thrombus volume was associated with rapid AAA volume increase ( ≥ 5 cm/y ) , independent of initial aortic diameter ( RR , 15.0 ; 95 % CI , 1.9 - 115.7 ; P = .009 ) . CONCLUSION In this small cohort , infrarenal aortic thrombus volume was associated with the incidence of cardiovascular events and AAA progression . These results need to be confirmed and mechanisms underlying the associations clarified in large further studies OBJECTIVE To investigate risk factors associated with aneurysm rupture using patients r and omized into the U.K. Small Aneurysm Trial ( n = 1090 ) or monitored for aneurysm growth in the associated study ( n = 1167 ) . SUMMARY BACKGROUND DATA The U.K. Small Aneurysm Trial has shown that ultrasound surveillance is a safe management option for patients with small abdominal aortic aneurysms ( 4.0 to 5.5 cm in diameter ) , with an annual rupture rate of 1 % . METHODS In the cohort of 2257 patients ( 79 % male ) , aged 59 to 77 years , 103 instances of abdominal aortic aneurysm rupture were identified during the 7-year period of follow-up ( 1991 - 1998 ) . Almost all patients ( 98 % ) had initial aneurysm diameters in the range of 3 to 6 cm , and the majority of ruptures ( 76 % ) occurred in patients with aneurysms > or = 5 cm in diameter . Kaplan-Meier survival and Cox regression analysis were used to identify baseline risk factors associated with aneurysm rupture . RESULTS After 3 years , the annual rate of aneurysm rupture was 2.2 % ( 95 % confidence interval 1.7 to 2.8 ) . The risk of rupture was independently and significantly associated with female sex ( p < 0.001 ) , larger initial aneurysm diameter ( p < 0.001 ) , lower FEV1 ( p = 0.004 ) , current smoking ( p = 0.01 ) , and higher mean blood pressure ( p = 0.01 ) . Age , body mass index , serum cholesterol concentration , and ankle/brachial pressure index were not associated with an increased risk of aneurysm rupture . CONCLUSIONS Within this cohort of patients , women had a threefold higher risk of aneurysm rupture than men . Effective control of blood pressure and cessation of smoking are likely to diminish the risk of rupture BACKGROUND Noncardiac surgery is associated with significant cardiovascular mortality , morbidity , and cost . Small trials of beta-blockers suggest that they may prevent cardiovascular events in patients undergoing noncardiac surgery , but trial results are inconclusive . We have initiated the POISE trial to definitively establish the effects of beta-blocker therapy in patients undergoing noncardiac surgery . METHODS The POISE trial is a blinded , r and omized , and controlled trial of controlled-release metoprolol versus placebo in 10000 patients at risk for a perioperative cardiovascular event who are undergoing noncardiac surgery . Patients will receive the study drug 2 to 4 hours before surgery and subsequently for 30 days . The primary outcome is a composite of cardiovascular death , nonfatal myocardial infa rct ion , and nonfatal cardiac arrest at 30 days . Patients will also be followed for events at 1 year . RESULTS To date , the POISE trial has recruited > 6300 patients in 182 centers in 21 countries . Currently , the patients ' mean age is 69 years ; 63 % are males , 43 % have a history of coronary artery disease , 43 % have a history of peripheral arterial disease , and 30 % have diabetes . Most participants have undergone vascular ( 42 % ) , intraabdominal ( 23 % ) , or orthopedic ( 19 % ) surgery . CONCLUSIONS The POISE trial is a large international trial that will provide a reliable assessment of the effects of beta-blocker therapy in patients undergoing noncardiac surgery OBJECTIVES Increasing numbers of patients with small abdominal aortic aneurysms ( AAA ) are being diagnosed . The aim of this paper is to define the fate of those patients undergoing surveillance of small AAAs .  SETTING U.K. district general hospital . METHODS A prospect i ve study has been carried out of all patients undergoing surveillance .  At the time of the first consultation the patient was assessed , a Detsky score calculated and the referral source noted . End points of the study were elective repair of the aneurysm , aneurysm rupture or death of the patient . RESULTS Details of 267 patients were analysed . The referral source was general practitioner in 39 % , patients with peripheral vascular disease in 32 % and department of urology in 21 % . None were referred from population screening . The cumulative 5-year risks of rupture , elective repair or non-AAA related deaths were 15 % , 26 % and 46 % for all patients , 4 % , 13 % and 38 % for patients initially presenting with AAA less than 4 cm diameter and 21 % , 42 % and 54 % for patients presenting with an AAA 4 - 5.5 cm diameter . All but one of 11 patients whose aneurysm ruptured were unfit or had declined elective repair . There were 56 non-AAA related deaths , the majority due to cardiovascular causes . Those patients with low Detsky scores had a 5-year survival of 62 % , those with high scores 44 % . The age/sex matched survival or a normal population at 5 years in 80 % . CONCLUSION Overall the non-AAA related mortality was greater than the risks of rupture or elective repair . It is important to bear in mind the poor prognosis of this group of patients compared with a normal population when considering elective repair of small AAAs BACKGROUND Perioperative myocardial ischemia is the single most important potentially reversible risk factor for mortality and cardiovascular complications after noncardiac surgery . Although more than 1 million patients have such complications annually , there is no effective preventive therapy . METHODS We performed a r and omized , double-blind , placebo-controlled trial to compare the effect of atenolol with that of a placebo on overall survival and cardiovascular morbidity in patients with or at risk for coronary artery disease who were undergoing noncardiac surgery .  Atenolol was given intravenously before and immediately after surgery and orally thereafter for the duration of hospitalization . Patients were followed over the subsequent two years . RESULTS A total of 200 patients were enrolled . Ninety-nine were assigned to the atenolol group , and 101 to the placebo group . One hundred ninety-four patients survived to be discharged from the hospital , and 192 of these were followed for two years . Overall mortality after discharge from the hospital was significantly lower among the atenolol-treated patients than among those who were given placebo over the six months following hospital discharge ( 0 vs. 8 percent , P<0.001 ) , over the first year ( 3 percent vs. 14 percent , P=0.005 ) , and over two years ( 10 percent vs. 21 percent , P=0.019 ) . The principal effect was a reduction in deaths from cardiac causes during the first six to eight months . Combined cardiovascular outcomes were similarly reduced among the atenolol-treated patients ; event-free survival throughout the two-year study period was 68 percent in the placebo group and 83 percent in the atenolol group ( P=0.008 ) . CONCLUSIONS In patients who have or are at risk for coronary artery disease who must undergo noncardiac surgery , treatment with atenolol during hospitalization can reduce mortality and the incidence of cardiovascular complications for as long as two years after surgery Objective : Cardiovascular complications represent a major cause of morbidity and mortality in patients undergoing vascular surgery . This was a prospect i ve r and omized , open-label study to investigate the effect of lipid-lowering treatment by statin monotherapy or intensified by combining statin with ezetimibe on a 12-month prognosis after vascular surgery . Methods : Patients were r and omly assigned to receive rosuvastatin ( RSV ) 10 mg/d or rosuvastatin 10 mg/d plus ezetemibe ( RSV/EZT ) 10 mg/d , starting prior to scheduled surgical procedure . The primary end point was the first major cardiovascular event , including death from cardiac causes , nonfatal myocardial infa rct ion , ischemic stroke , and unstable angina . Results : A total of 136 patients assigned to RSV and 126 to RSV/EZT completed the study protocol . As many as 6.6 % of patients in the RSV group experience a major cardiovascular event within 30 days after surgery versus 5.6 % in the RSV/EZT group ( P = .72 ) . From month 1 to 12 of the follow-up period , primary end point was observed ( 9 taking RSV vs 2 in the RSV/EZT group [ P = .04 ] ) . Intensified lipid-lowering therapy with RSV/EZT was associated with a greater decrease in low-density lipoprotein cholesterol levels compared with RSV ( 75.87 ± 31.64 vs 87.19 ± 31.7 , P = .004 ) , while no differential effect on triglyceride , high-density lipoprotein cholesterol or high-sensitivity C-reactive protein levels was noted between groups . Conclusion : Our findings indicate that statin therapy intensified by ezetimibe may reduce the incidence of cardiovascular events within the first 12 months after vascular surgery . Nonetheless , whether the use of ezetimibe as an add-on therapy to reduce cardiovascular risk in these patients needs to be tested in larger future studies BACKGROUND Endovascular aneurysm repair ( EVAR ) is a new technology to treat patients with abdominal aortic aneurysm ( AAA ) when the anatomy is suitable . Uncertainty exists about how endovascular repair compares with conventional open surgery . EVAR trial 1 was instigated to compare these treatments in patients judged fit for open AAA repair . METHODS Between 1999 and 2003 , 1082 elective ( non-emergency ) patients were r and omised to receive either EVAR ( n=543 ) or open AAA repair ( n=539 ) . Patients aged at least 60 years with aneurysms of diameter 5.5 cm or more , who were fit enough for open surgical repair ( anaesthetically and medically well enough for the procedure ) , were recruited for the study at 41 British hospitals proficient in the EVAR technique . The primary outcome measure is all-cause mortality and these results will be released in 2005 . The primary analysis presented here is operative mortality by intention to treat and a secondary analysis was done in per- protocol patients . FINDINGS Patients ( 983 men , 99 women ) had a mean age of 74 years ( SD 6 ) and mean AAA diameter of 6.5 cm ( SD 1 ) . 1047 ( 97 % ) patients underwent AAA repair and 1008 ( 93 % ) received their allocated treatment . 30-day mortality in the EVAR group was 1.7 % ( 9/531 ) versus 4.7 % ( 24/516 ) in the open repair group ( odds ratio 0.35 [ 95 % CI 0.16 - 0.77 ] , p=0.009 ) . By per- protocol analysis , 30-day mortality for EVAR was 1.6 % ( 8/512 ) versus 4.6 % ( 23/496 ) for open repair ( 0.33 [ 0.15 - 0.74 ] , p=0.007 ) . Secondary interventions were more common in patients allocated EVAR ( 9.8 % vs 5.8 % , p=0.02 ) . INTERPRETATION In patients with large AAAs , treatment by EVAR reduced the 30-day operative mortality by two-thirds compared with open repair . Any change in clinical practice should await durability and longer term results Objectives : We explored whether preoperative rosuvastatin could protect the cardiac health of patients with coronary artery disease undergoing emergency , noncardiac surgery . Methods : We r and omized 550 noncardiac emergency surgery patients with stable coronary artery disease on long-term statin therapy to treatment with and without preoperative rosuvastatin .  All patients received rosuvastatin after surgery . We evaluated the incidence of myocardial necrosis and major adverse cardiovascular and cerebrovascular events ( MACCE ) 30 days and 6 months after surgery . Results : Creatinine kinase-myocardial b and ( CK-MB ) isoform elevations occurred less frequently 12 and 24 h after noncardiac emergency surgery in the experimental group than in the control group ( p = 0.029 ) . After surgery , the incidence of MACCE was also lower in the experimental group than in the control group ( p = 0.019 ) . The difference was mainly due to the incidence of perioperative myocardial infa rct ion ( p = 0.029 ) . Multivariable analysis found that rosuvastatin reload reduced the incidence of MACCE 52 % 6 months after surgery ( p = 0.03 ) . Conclusions : Preoperative rosuvastatin reload therapy decreases the incidence of myocardial necrosis and MACCE after noncardiac emergency surgery in patients with stable coronary artery disease on long-term statin therapy Objectives This study aim ed to ( a ) investigate whether atorvastatin reload protects against acute heart failure ( AHF ) in patients with stable coronary artery disease ( CAD ) undergoing noncardiac emergency surgery and decreases the incidence of major adverse cardiac events ( MACE ) during hospitalization and ( b ) eluci date its possible mechanism of action . Material s and methods In total , 500 patients with stable CAD before noncardiac emergency surgery were r and omized either to the atorvastatin reload or to the  placebo group . All patients received atorvastatin treatment postoperatively . The primary end point was the incidence of AHF during hospitalization , and the secondary end point was the incidence of MACE during hospitalization . Preoperative and 72 h postoperative changes in high-sensitivity C-reactive protein and interleukin-6 levels were compared between the two groups . Results AHF during hospitalization occurred in 5.2 % of patients in the atorvastatin reload group and 11.2 % in the placebo group ( P=0.0225 ) . MACE during hospitalization occurred in 2.4 % of patients in the atorvastatin reload group and 8.0 % in the placebo group ( P=0.0088 ) . According to multivariable analysis , atorvastatin reload conferred a 50 % reduction in the risk of AHF during hospitalization ( odds ratio , 0.50 ; 95 % confidence interval , 0.2–0.8 ; P=0.005 ) . The median decrease in the high-sensitivity C-reactive protein and interleukin-6 levels was significantly greater in the atorvastatin reload group ( P<0.001 ) . Conclusion Atorvastatin reload may improve the clinical outcome of patients with stable CAD undergoing noncardiac emergency surgery by decreasing the incidence of AHF and MACE during hospitalization . The mechanism of this protective effect may involve inhibition of inflammation OBJECTIVE The purpose of this study was to assess prospect ively the incidence , health care re source utilization , and economic burden associated with perioperative myocardial ischemic injury ( PMII ) in high-risk patients undergoing noncardiac vascular surgery . METHODS Two hundred thirty-six patients consented to participate in a pharmacoeconomic sub study as part of a r and omized , multicenter clinical trial . Patients were assessed for  myocardial ischemic injury  by using clinical , biochemical , and electrocardiographic criteria . PMII was defined as fatal or nonfatal myocardial infa rct ion , new or worsened congestive heart failure , or new arrhythmias . Re source utilization parameters were compared for patients with and without PMII . Patients underwent the following index procedures : open abdominal aortic aneurysm repair ( n = 44 ) ,  bypass for aortoiliac disease ( n = 29 ) , bypass for femoropopliteal disease ( n = 62 ) , bypass for femorotibial disease ( n = 71 ) , extra-anatomic bypass ( n = 23 ) , and miscellaneous ( n = 7 ) . Patients undergoing carotid endarterectomy or only endovascular interventions were excluded . The incremental cost of PMII was estimated by applying the average costs ( adjusted to 2004 US dollars ) of the hospital ward ( dollar 700.00/d ) or intensive care unit ( dollar 2500.00/d ) to the length of stay differences for patients with and without PMII . RESULTS The overall mortality was 3.4 % ( 8/236 ) , and 7 of 8 deaths were related to PMII . PMII occurred in 42 ( 17.8 % ) of 236 patients : 22 myocardial infa rct ions , 11 congestive heart failures , and 12 new arrhythmias ( 3 patients had 2 PMII events ) . There was no evidence of differences in the incidence of PMII among the various index procedures . PMII was associated with a dramatic increase in re source utilization . The mean length of stay was 16.8 and 10.0 days for patients with and without PMII , respectively ( P < .001 ) . Intensive care unit care was required by 35 ( 83.3 % ) of 42 patients with and 121 ( 62.4 % ) of 194 patients without PMII ( P < .009 ) . The mean intensive care unit length of stay was 6.6 and 3.7 days for patients with and without PMII , respectively ( P < .009 ) . Ten ( 23.8 % ) of 42 patients with and 20 ( 10.3 % ) of 194 patients without PMII returned to the emergency department for care after discharge ( P < .02 ) . CONCLUSIONS In modern vascular surgery practice , PMII remains common despite the availability of beta-blockers and other preventative strategies . PMII is associated with dramatic increases in re source utilization and cost . The increase in re source utilization associated with PMII result ed in an estimated incremental cost per patient of dollar 9980.00 . If 250,000 high-risk open vascular operations are performed annually in the United States , the economic burden of PMII in these procedures alone approximates dollar 444 million . Strategies to decrease PMII incidence and severity should be evaluated in large-scale prospect i ve trials BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery . METHODS We performed a r and omized , multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infa rct ion within 30 days after major vascular surgery in patients at high risk for these events . High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography . Eligible patients were r and omly assigned to receive st and ard perioperative care or st and ard care plus perioperative beta-blockade with bisoprolol . RESULTS A total of 1351 patients were screened , and 846 were found to have one or more cardiac risk factors . Of these 846 patients , 173 had positive results on dobutamine echocardiography . Fifty-nine patients were r and omly assigned to receive bisoprolol , and 53 to receive st and ard care .  Fifty-three patients were excluded from r and omization because they were already taking a beta-blocker , and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing . Two patients in the bisoprolol group died of cardiac causes ( 3.4 percent ) , as compared with nine patients in the st and ard-care group ( 17 percent , P=0.02 ) . Nonfatal myocardial infa rct ion occurred in nine patients given st and ard care only ( 17 percent ) and in none of those given st and ard care plus bisoprolol ( P<0.001 ) . Thus , the primary study end point of death from cardiac causes or nonfatal myocardial infa rct ion occurred in 2 patients in the bisoprolol group ( 3.4 percent ) and 18 patients in the st and ard-care group ( 34 percent , P<0.001 ) . CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infa rct ion in high-risk patients who are undergoing major vascular surgery The optimal dosing strategy for  perioperative beta-blockers  to safely achieve recommended target heart rates ( HRs ) by current guidelines is not well defined . An HR-titrated perioperative beta-blocker dosing regimen versus a fixed-dose regimen was assessed by clinical outcomes , postoperative heart rate , and beta-blocker-related complications .  Patients ( n = 64 ) scheduled to undergo moderate- to high-risk vascular surgery and without contraindications to beta-blockade were r and omized to either a fixed-dose or HR-titrated beta-blocker dosing schedule . Clinical outcomes and HRs were followed immediately preoperatively to 24 hr postoperatively . A difference in mean HR between the two dosing arms was significant immediately postoperatively ( 70.1 vs. 58.2 bpm for fixed dose and HR-titrated arms , respectively ; p = 0.012 ) but at no other time points . However , the HR-titrated strategy led to a significant reduction in the percentage of HR measurements > 80 bpm ( 34.5 % vs. 16.1 % , p < 0.001 ) and to a significant reduction in absolute HR change ( 17.5 vs. 22.5 bpm , p = 0.034 ) . There were no significant differences in the occurrence of asymptomatic hypotension between the two study arms , and no beta-blocker-related adverse events occurred in either study arm . An aggressive , HR-titrated perioperative beta-blocker dosing strategy was associated with more consistent maintenance of postoperative HRs within the range recommended by current guidelines and did not result in increased drug-related adverse events . The question of what is the best perioperative beta-blocker dosing regimen warrants further evaluation in a large-scale clinical trial Purpose Evidence suggests that statins reduce cardiovascular complications in patients undergoing noncardiac surgery , although questions remain regarding the mechanism of benefit and the preferred dosing strategy . In this trial , we evaluated the perioperative effects on C-reactive protein ( CRP ) that result ed from starting atorvastatin within seven days of noncardiac surgery . The objective was to identify anti-inflammatory effects of atorvastatin prior to conducting a large r and omized trial with clinical end points . Methods In a single centre , parallel group , placebo-controlled trial , sixty high cardiac risk participants over age 45 yr undergoing noncardiac surgery were assigned r and omly to one of three groups to receive atorvastatin 80 mg ( A ) and /or placebo ( P ) . Group AA ( n = 26 ) received atorvastatin seven days before surgery , the day of surgery , and for seven days post surgery . Group PA ( n = 17 ) received placebo seven days before surgery , atorvastatin on the day of surgery , and atorvastatin for seven days post surgery . Group PP ( n = 17 ) received placebo at all times . All participants , health care professionals , research assistants , and outcome adjudicators were masked to treatment allocation . Analyses were by intention to treat . The primary outcome was the C-reactive protein level at 48 hr . Results Fifty-six participants completed the 30-day follow-up . The mean ( st and ard deviation ) changes in CRP levels from baseline at 48 hr in Groups AA , PA , and PP were 141.0 ( 72.4 ) , 153.5 ( 42.2 ) , and 111.2 ( 84.6 ) , respectively . The mean differences ( 95 % confidence interval ) at 48 hr for AA vs PA , AA vs PP , and PA vs PP were : −20.1 ( −81.2 to 41.1 ) , 22.7 ( −31.7 to 77.2 ) , and 42.8 ( −20.0 to 105.7 ) , respectively , adjusting for baseline CRP , type of procedure , presence of coronary artery disease , use of medications , and for multiple comparisons using Tukey ’s method . Conclusions Administration of atorvastatin , initiated within seven days preoperatively , was not associated with clinical ly significant reductions in CRP levels . ( Clinical Trials.gov number , NCT00967434).RésuméObjectifDes données probantes suggèrent que les statines réduisent les complications cardiovasculaires chez des patients subissant une chirurgie non cardiaque bien que des questions demeurent concernant le mécanisme de ce bénéfice et la meilleure stratégie posologique à adopter . Au cours de cette étude , nous avons évalué les effets périopératoires sur la protéine C-réactive ( CRP ) résultant d’une prise d’atorvastatine commençant dans les sept jours précédant une chirurgie non cardiaque . L’objectif était d’identifier les effets anti-inflammatoires de l’atorvastatine avant de mener une gr and e étude r and omisée comportant des critères cliniques d’évaluation . MéthodesSoixante participants d’un seul centre , à risque cardiaque élevé , âgés de plus de 45 ans et devant subir une chirurgie non cardiaque , ont participé à une étude r and omisée contre placebo et à groupes parallèles ; ils ont été r and omisés dans l’un des trois groupes pour y recevoir de l’atorvastatine 80 mg ( A ) et/ou un placebo ( P ) . Les patients du groupe AA ( n = 26 ) ont reçu de l’atorvastatine pendant sept jours avant la chirurgie , le jour de la chirurgie , et pendant sept jours après l’intervention chirurgicale . Les patients du groupe PA ( n = 17 ) ont reçu un placebo pendant sept jours avant la chirurgie , de l’atorvastatine le jour de la chirurgie et pendant sept jours après l’intervention chirurgicale . Les patients du groupe PP ( n = 17 ) ont reçu un placebo pendant toute la durée de l’étude . Tous les participants ( professionnels de soins de santé , assistants de recherche et évaluateurs des résultats ) ignoraient l’assignation au groupe de traitement . Les analyses ont été réalisées sur l’intention de traiter . Le principal critère d’évaluation était le taux de protéine C-réactive à 48 heures . RésultatsCinquante-six participants ont terminé le suivi de 30 jours . Les variations moyennes ( écart-type ) des concentrations de CRP à 48 heures par rapport à la ligne de base dans les groupes AA , PA et PP ont été , respectivement , de 141,0 ( 72,4 ) , 153,5 ( 42,2 ) et de 111,2 ( 84,6 ) . Les différences moyennes ( intervalle de confiance à 95 % ) à 48 heures pour les groupes AA contre PA , AA contre PP et PA contre PP ont été , respectivement : −20,1 ( −81,2 à 41,1 ) , 22,7 ( −31,7 à77,2 ) , et 42,8 ( −20,0 à 105,7 ) , après ajustement pour la CRP à la ligne de base , le type d’intervention , la présence d’une coronaropathie , l’utilisation de médicaments et pour les comparaisons multiples selon la méthode de Tukey . Conclusions L’administration d’atorvastatine , débutée dans les sept jours précédant une intervention chirurgicale n’a pas été associée à des baisses cliniquement significatives des concentrations de CRP . ( Numéro Clinical Trials.gov : NCT00967434 ) We compared the effects of lipid lowering with rosuvastatin ( RSV ) monotherapy versus intensified treatment by combining RSV with ezetimibe ( EZT ) on kidney function in patients undergoing vascular surgery . Patients were r and omly assigned to either 10 mg/d RSV ( n = 136 ) or RSV 10 mg/d plus EZT 10 mg/d ( RSV/EZT , n = 126 ) . At 12 months , a similar decrease in estimated glomerular filtration rate ( eGFR ) was noted . Patients who achieved a low-density lipoprotein cholesterol ( LDL-C ) of < 100 mg/dL had less eGFR decrease than those patients having an LDL-C limit of more than 100 mg/dL. There were no significant changes in the urinary total protein to creatinine ratio in either group . Significant microalbuminuria was evident in both the groups . Patients undergoing vascular surgery show deterioration in their renal function during the first year , despite statin therapy . Intensified lipid-lowering therapy by adding EZT does not appear to have any renoprotective effect Abdominal aortic aneurysm is common . The aim of this study was to assess the effect of smoking on prevalence and management .  Patients attending the vascular unit and appropriate controls were prospect ively recruited . A smoking history revealed tobacco exposure in pack years . Serum cotinine was assessed biochemically . Independent risk factors were statistically determined . In all , 202 ( 186 men ) patients were recruited , with 202 ( 197 men ) controls . A total of 69 patients tested positive for cotinine , whereas 39 controls were positive ( P = .001 ) . Smoking and ischemic heart disease were significant predictors for aneurysm prevalence . Cardiac disease emerged as a more important predictor than smoking in symptomatic patients . In noncardiac patients , smoking and hypercholesterolemia were significant risk factors . Smoking is a significant predictor for aneurysm development . In high-risk patients , the cardiac disease process is the most important factor , with control of this imperative . However , in noncardiac patients , smoking cessation and lipid-lowering therapy are crucial BACKGROUND Adverse cardiac events are common after vascular surgery . We hypothesized that perioperative statin therapy would improve postoperative outcomes . METHODS In this double-blind , placebo-controlled trial , we r and omly assigned patients who had not previously been treated with a statin  to receive , in addition to a beta-blocker , either 80 mg of extended-release fluvastatin or placebo once daily before undergoing vascular surgery .  Lipid , interleukin-6 , and C-reactive protein levels were measured at the time of r and omization and before surgery . The primary end point was the occurrence of myocardial ischemia , defined as transient electrocardiographic abnormalities , release of troponin T , or both , within 30 days after surgery . The secondary end point was the composite of death from cardiovascular causes and myocardial infa rct ion . RESULTS A total of 250 patients were assigned to fluvastatin  , and 247 to placebo , a median of 37 days before vascular surgery . Levels of total cholesterol , low-density lipoprotein cholesterol , interleukin-6 , and C-reactive protein were significantly decreased in the fluvastatin group but were unchanged in the placebo group . Postoperative myocardial ischemia occurred in 27 patients ( 10.8 % ) in the fluvastatin group and in 47 ( 19.0 % ) in the placebo group ( hazard ratio , 0.55 ; 95 % confidence interval [ CI ] , 0.34 to 0.88 ; P=0.01 ) . Death from cardiovascular causes or myocardial infa rct ion occurred in 12 patients ( 4.8 % ) in the fluvastatin group and 25 patients ( 10.1 % ) in the placebo group ( hazard ratio , 0.47 ; 95 % CI , 0.24 to 0.94 ; P=0.03 ) . Fluvastatin therapy was not associated with a significant increase in the rate of adverse events . CONCLUSIONS In patients undergoing vascular surgery , perioperative fluvastatin therapy was associated with an improvement in postoperative cardiac outcome . ( Current Controlled Trials number , IS RCT N83738615 . BACKGROUND The relationship between numerous risk factors and perioperative mortality after cardiovascular surgery has been studied extensively . While improved perioperative survival and fewer cardiovascular events have been related to statin therapy , its effect on long-term survival after aneurysm repair remains to be eluci date d. The aim of this study is to determine the effect of statin therapy on long-term survival after open and endovascular aneurysm repair and to identify other cardiovascular and patient-related risk factors in this respect . METHODS A post-hoc analysis of a r and omized trial comparing open and endovascular abdominal aortic aneurysm repair was performed . In this multicenter trial , 351 patients were r and omly assigned to undergo either open abdominal aortic aneurysm repair or endovascular repair . Patients who were on lipid-lowering medication at their inclusion in the trial ( n = 135 ) were compared with those who were not ( n = 216 ) . RESULTS During 6 years of follow-up , 118 ( 33.6 % ) patients died after r and omization . Statin therapy , baseline characteristics , Society for Vascular Surgery/International Society for Cardiovascular Surgery risk factors , aneurysm size , re interventions , antiplatelet or anticoagulant agents , and β-blockers were used to identify prognostic factors influencing survival . After identification of significant factors in a Kaplan-Meier analysis , a multivariable Cox regression analysis was applied . Statin therapy at inclusion in the trial was independently associated with better overall survival after open or endovascular aneurysm repair ( hazard ratio [ HR ] , 0.5 ; 95 % confidence interval [ CI ] , 0.3 - 0.8 ; P = .004 ) . Statins were especially associated with fewer cardiovascular deaths ( HR , 0.4 ; 95 % CI , 0.2 - 0.9 ; P = .025 ) . Several risk factors were associated with poor survival after open and endovascular aneurysm repair : age > 70 ( HR , 3.4 ; 95 % CI , 2.2 - 5.0 ; P < .001 ) , a history of cardiac disease at baseline ( HR , 1.9 ; 95 % CI , 1.3 - 2.8 ; P = .001 ) , and moderate/severe tobacco use ( HR , 1.7 ; 95 % CI , 1.2 - 2.5 ; P = .004 ) . Gender , aneurysm size , the need for reintervention , pulmonary disease , renal disease , carotid disease , hypertension , diabetes mellitus , antiplatelet or anticoagulant agents , and β-blockers were not significantly associated with impaired long-term survival ( P > .05 ) . CONCLUSIONS Despite the limitations of a post-hoc analysis of a prospect ively maintained trial , we conclude that statin therapy at the beginning of the trial is independently associated with improved long-term survival after open or endovascular aneurysm repair , while age above 70 years , a history of cardiovascular disease , and tobacco use are associated with decreased long-term survival
target: Due to the limited number of included trials , there is insufficient evidence to draw any conclusions about the effectiveness of cardiovascular prophylaxis in reducing mortality and cardiovascular events in people with AAA .
background: BACKGROUND Pharmacological prophylaxis has been proven to reduce the risk of cardiovascular events in individuals with atherosclerotic occlusive arterial disease .
  However , the role of prophylaxis in individuals with abdominal aortic aneurysm ( AAA ) remains unclear .
  Several studies have shown that despite successful repair , those people with AAA have a poorer rate of survival than healthy controls .
  People with AAA have an increased prevalence of coronary heart disease and risk of cardiovascular events .
  Despite this association , little is known about the effectiveness of pharmacological prophylaxis in reducing cardiovascular risk in people with AAA .
  This is an up date of a Cochrane review first published in 2014 .
  OBJECTIVES To determine the long-term effectiveness of antiplatelet , antihypertensive or lipid-lowering medication in reducing mortality and cardiovascular events in people with abdominal aortic aneurysm ( AAA ) .