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Original Contribution |

Lipid-Lowering Therapy and In-Hospital Mortality Following Major Noncardiac Surgery FREE

Peter K. Lindenauer, MD, MSc; Penelope Pekow, PhD; Kaijun Wang, MS; Benjamin Gutierrez, PhD; Evan M. Benjamin, MD
[+] Author Affiliations

Author Affiliations: Division of Healthcare Quality, Baystate Medical Center, Springfield, Mass (Drs Lindenauer, Pekow, and Benjamin); Department of Medicine, Tufts University School of Medicine, Boston, Mass (Drs Lindenauer and Benjamin); School of Public Health and Health Sciences, University of Massachusetts, Amherst (Dr Pekow and Mr Wang); Premier Healthcare Informatics, Premier Incorporated, Charlotte, NC (Dr Gutierrez).


JAMA. 2004;291(17):2092-2099. doi:10.1001/jama.291.17.2092.
Text Size: A A A
Published online

Context Cardiovascular complications following major noncardiac surgery are an important source of perioperative morbidity and mortality. Although lipid-lowering medications are considered a key component in the primary and secondary prevention of cardiovascular disease, their potential benefit during the perioperative period is uncertain.

Objective To examine the association between treatment with lipid-lowering medications and in-hospital mortality following major noncardiac surgery.

Design, Setting, and Patients A retrospective cohort study based on hospital discharge and pharmacy records of 780 591 patients aged 18 years or older who underwent major noncardiac surgery from January 1, 2000, to December 31, 2001, at any 1 of 329 hospitals throughout the United States. Only patients who survived through at least the second hospital day were included. Lipid-lowering therapy was defined as use during the first 2 hospital days. Propensity matching was used to adjust for numerous baseline differences.

Main Outcome Measure In-hospital mortality.

Results Of the 780 591 patients, 77 082 patients (9.9%) received lipid-lowering therapy perioperatively and 23 100 (2.96%) died during the hospitalization. Treatment with lipid-lowering agents was associated with lower crude mortality (2.13% vs 3.05%, P<.001). In an analysis using matching by propensity score, 1595 patients (2.18%) treated with lipid-lowering medications died compared with 4158 patients (3.15%) who did not receive therapy or in whom treatment was initiated after the second day (P<.001). After adjusting for residual differences in the propensity matched groups using conditional logistic regression, risk of mortality remained lower among treated patients (adjusted odds ratio [OR], 0.62; 95% confidence interval [CI], 0.58-0.67). Based on this adjusted OR, the number needed to treat to prevent a postoperative death in the propensity matched cohort was 85 (95% CI, 77-98) and varied from 186 among patients at lowest risk to 30 among those with a revised cardiac risk index score of 4 or more. In a further analysis using the entire study cohort and adjusting for quintile of propensity, a significant effect of treatment persisted (adjusted OR, 0.71; 95% CI, 0.67-0.75).

Conclusions Treatment with lipid-lowering agents may reduce risk of death following major noncardiac surgery. Clinical trials are required to confirm this observation.

Figures in this Article

Approximately 24 million surgical operations are performed each year at hospitals across the United States1 and it is estimated that as many as 1 million of these operations will be complicated by a perioperative cardiovascular event.2 Perioperative myocardial infarction is a dreaded occurrence that is associated with prolonged hospital stay, substantial morbidity, and mortality rates as high as 25% to 40%.3,4 Among patients undergoing major noncardiac surgery, the overall incidence of perioperative myocardial infarction is 2% to 3%, and within high-risk populations, such as those patients undergoing vascular surgery, rates can be as high as 34%.5,6 Although clinical prediction instruments5,79 have improved the ability to detect patients at risk of perioperative cardiac events, effective prevention strategies remain limited.10 The emergence of perioperative β-blockade appears to be a major therapeutic advance,11,12 yet rates of perioperative cardiovascular complications among the highest-risk patients treated with β-blockers can reach 16%.13,14 Additional prevention modalities are therefore still needed to improve patient safety and outcomes following surgery.

Lipid-lowering therapy is considered a cornerstone in the primary and secondary prevention of cardiovascular disease. In addition to inhibiting development of atherosclerotic plaques through reduction of serum cholesterol, lipid-lowering medications are anti-inflammatory, can improve endothelial function and coagulation, and produce a stabilizing effect on vulnerable plaques.15 These properties may be especially beneficial in the perioperative period because the disruption of unstable plaques is believed to be responsible for most cases of perioperative myocardial infarction.16 We therefore sought to determine whether the use of lipid-lowering medication was associated with reduced mortality among patients undergoing major noncardiac surgery.

Data Source and Patients

A retrospective cohort study was performed using data from 329 hospitals throughout the United States that participated in Perspective, a database developed for quality and utilization benchmarking by Premier Incorporated, Charlotte, NC. In addition to the data elements available in the standard hospital discharge file, the Perspective database contains a date-stamped log of all billed items, including medications, laboratory, diagnostic, and therapeutic services, at the individual patient level.

Patients were included in our analysis if they were 18 years or older, underwent major noncardiac surgery between January 1, 2000, and December 31, 2001, and survived beyond the second hospital day. Surgical procedures were categorized by using a health information system, all patient refined-diagnosis related groups (APR-DRG, version 15.0, 3M Corp, Minneapolis, Minn) and were considered major if the median length of stay for patients in the diagnosis related groups was 3 days or more.5 Patients undergoing obstetrical procedures were excluded. Permission to perform the study was obtained and informed consent was waived by the institutional review board at Baystate Medical Center, Springfield, Mass.

Data Collection

For each case we noted type of surgery, whether the admission was elective, urgent, or emergent, and at which hospital the operation was performed. In addition to age, sex, race, and insurance status, we recorded the presence of the following comorbidities: ischemic heart disease, congestive heart failure, cerebrovascular disease, diabetes mellitus, renal insufficiency, chronic obstructive pulmonary disease, hypertension, and hyperlipidemia. Comorbidities were established using a combination of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) secondary diagnoses. Patients with diabetes mellitus were identified on the basis of either a secondary diagnosis of diabetes mellitus or treatment with an oral hypoglycemic agent during the hospitalization. Perioperative administration of β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, antiplatelet agents, loop diuretics, thiazide diuretics, antiarrhythmics, dopamine, and dobutamine were assessed using pharmacy records. Prophylactic antibiotic administration and use of pharmacologic and mechanical measures for the prevention of venous thromboembolism were obtained similarly. In-hospital mortality, length of stay, and actual costs were obtained from the Perspective discharge file. In addition to the information related to the admission, we noted each hospital's bed size, teaching status, geographic region, and whether it was located in an urban or rural setting.

Lipid-Lowering Therapy

To examine treatment with lipid-lowering agents, we used pharmacy records to identify whether a lipid-lowering medication was administered at any time during the hospitalization, and if so, the date the medication was first administered. Because lipid-lowering agents are frequently initiated for secondary prevention soon after a postoperative myocardial infarction, we grouped patients in whom the drugs were first administered on day 3 or later with those patients in whom the medications were never used. Patients treated on the first or second hospital day were categorized as having received either statin-based or nonstatin-based therapy. Those patients who received combination therapy that included a statin were analyzed in the statin group.

Statistical Analysis

Based on an article by Lee et al,5 we calculated a revised cardiac risk index score for each patient, assigning 1 point for each of the following risk factors: high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, renal insufficiency, and diabetes mellitus. The category labelled high-risk surgery included all intrathoracic, intraperitoneal, and suprainguinal vascular procedures. Summary statistics for the overall sample were constructed by using frequencies and proportions for categorical data and mean, medians, and interquartile ranges for continuous variables. We compared patients who received perioperative treatment with lipid-lowering agents with those patients in whom the initiation of lipid-lowering therapy was delayed beyond the second hospital day, or in whom the drugs were never used. χ2 and z tests were used to assess the relationship between treatment with lipid-lowering agents and in-hospital mortality and any potential confounders.

We created a nonparsimonious logistic regression model to derive a propensity score for treatment with lipid-lowering therapy that included all patient and hospital characteristics as well as selected interaction terms. Patients missing any data elements were excluded from multivariable analysis. We matched each patient in the treated group with up to 2 in the nontreated or late-treated group based on propensity score. The matched cohort was then evaluated for differences between treatment groups for each of the potential confounding factors. Conditional logistic regression was used to assess the effect of lipid-lowering therapy on in-hospital mortality, adjusting for covariates unbalanced between groups (P<.01).17 In addition, using the complete cohort, we constructed a logistic regression model for in-hospital mortality using all available covariates, as well as a model adjusting for quintile of propensity score and covariates unbalanced across quintiles with P<.01. Interactions between lipid-lowering therapy and unbalanced covariates were also evaluated for each model and retained if P<.05. The Hosmer-Lemeshow goodness-of-fit test and the area under the curve were used to assess model fit.

To explore differences among specific lipid-lowering therapies, we compared mortality among statin users and nonstatin users with the nontreated or late-treated group, estimating the unadjusted odds ratios (ORs) with 95% confidence intervals (CIs). All analyses were performed using SAS version 8.2 (SAS Institute Inc, Cary, NC).

A total of 780 591 patients aged 18 years or older underwent major noncardiac surgery during the study period and were included in the analysis. The median age of the patients was 64 years, 55% were women, and 68% were white (Table 1). Hypertension, diabetes mellitus, and ischemic heart disease were the most commonly noted comorbidities and 55% of the patients had a revised cardiac risk index score of 1 or more. Orthopedic and abdominal operations accounted for 68% of cases, 30% of the procedures were labeled high-risk, and 50% of admissions were elective. The median length of stay was 5 days (Table 2). A total of 23 100 study patients (2.96%) died during the hospitalization. The majority of participating hospitals were in the south; most were medium-sized, nonteaching, and located in urban areas (Table 3).

Table Graphic Jump LocationTable 1. Demographic and Clinical Characteristics of Patients Undergoing Major Noncardiac Surgery*
Table Graphic Jump LocationTable 2. Administrative Characteristics of Patients Undergoing Major Noncardiac Surgery and Mortality Rate*
Table Graphic Jump LocationTable 3. Characteristics of Hospitals Participating in Study

A total of 77 082 patients (9.9%) were treated with lipid-lowering therapy on the first or second hospital day. Of these patients, 70 159 (91%) received a statin either alone or in combination with a nonstatin agent. Mean rates of perioperative lipid-lowering therapy varied from 7.1% at hospitals sized with 1 to 200 beds to 12.4% at hospitals with more than 800 beds. A total of 31 448 patients (26%) with documented ischemic heart disease received treatment in the early perioperative period.

Patients treated with lipid-lowering agents were older, were more often white men, had a higher number of comorbidities, and a higher revised cardiac risk index score than those patients who were not treated. Treated patients were more likely to have undergone orthopedic or vascular procedures, to have been admitted electively, and to list Medicare as their primary form of insurance. They were more likely to be administered β-blockers and other cardiovascular agents, and to receive measures to prevent venous thromboembolism. One thousand six hundred forty patients (2.13%) who were treated with lipid-lowering agents on the first or second day died compared with 21 460 patients (3.05%) in whom treatment was delayed beyond the second day or was not administered (P<.001).

Seventeen patients were excluded from multivariable analysis because of missing information. We successfully matched at least 1 nontreated patient based on propensity score for 73 050 patients (95%) in the treated group (76% with 2 matches and 19% with 1 match) (Table 4 and Table 5). In this propensity matched cohort, 1595 patients (2.18%) treated with lipid-lowering medications died compared with 4158 patients (3.15%) who did not receive therapy or in whom treatment was initiated after the second day (P<.001). A number of covariates remained unbalanced in the matched cohort. In a conditional logistic model using the matched cohort that adjusted for unbalanced covariates, the perioperative administration of lipid-lowering medications was associated with an adjusted OR of in-hospital mortality of 0.62 (95% CI, 0.58-0.67) (Table 6). Among this group of patients, the number needed to treat was 85 (95% CI, 77-98) and this varied with cardiac risk, ranging from 186 among the 34% of patients with no risk factors to 30 among the 2% of patients with an index of 4 or more (Table 7). No significant interactions with lipid-lowering therapy were found for any of the covariates included in the model.

Table Graphic Jump LocationTable 4. Demographic and Clinical Characteristics of Patients Who Did or Did Not Receive Lipid-Lowering Therapy in Propensity Matched Cohort*
Table Graphic Jump LocationTable 5. Administrative Characteristics of Patients Who Did or Did Not Receive Lipid-Lowering Therapy in Propensity Matched Cohort and Mortality Rate
Table Graphic Jump LocationTable 6. Odds Ratio of In-Hospital Mortality Associated With Perioperative Lipid-Lowering Therapy
Table Graphic Jump LocationTable 7. Number Needed to Treat in Propensity Matched Cohort by Revised Cardiac Risk Index Score

Using the full study cohort and adjusting for quintile of propensity, treatment with lipid-lowering therapy was associated with decreased mortality among patients in all but the lowest quintile of propensity (Figure 1). In the overall sample, the quintile-adjusted OR of in-hospital mortality was 0.71 (95% CI, 0.67-0.75) (Figure 2). With the exception of those patients least likely to receive treatment with lipid-lowering therapy, treatment was associated with similar mortality benefits across propensity quintiles. When adjusting for covariates that remained unbalanced after propensity matching, the OR for mortality among the overall sample of patients treated with lipid-lowering therapy was 0.67 (95% CI, 0.63-0.71).

Figure 1. In-Hospital Mortality Associated With Lipid-Lowering Therapy in Propensity Based Quintiles
Graphic Jump Location
Error bars indicate 95% confidence intervals. Seventeen patients (0.002%) were excluded from multivariable analysis due to missing data; therefore, among 780 574 patients, mean lipid-lowering therapy use per quintile of propensity was 0.5% (quintile 1, n = 156 114), 1.9% (quintile 2, n = 156 115), 9.8% (quintile 3, n = 156 115), 10.9% (quintile 4, n = 156 115), and 31.3% (quintile 5, n = 156 115).
Figure 2. Adjusted Odds Ratios of In-Hospital Mortality Associated With Lipid-Lowering Therapy Stratified by Quintile of Propensity
Graphic Jump Location
Seventeen patients (0.002%) were excluded from multivariable analysis due to missing data; therefore, among 780 574 patients, mean lipid-lowering therapy use per quintile of propensity was 0.5% (quintile 1, n = 156 114), 1.9% (quintile 2, n = 156 115), 9.8% (quintile 3, n = 156 115), 10.9% (quintile 4, n = 156 115), and 31.3% (quintile 5, n = 156 115).

In a standard multivariable logistic regression model (Table 6) that adjusted for age, sex, race, admission type, procedure type, comorbidities, revised cardiac risk index score, other medication use, insurance type, and hospital characteristics, the perioperative administration of lipid-lowering medications was associated with an adjusted OR of in-hospital mortality of 0.71 (95% CI, 0.67-0.75).

In an unadjusted analysis, the benefits of statins, administered either alone or in combination with nonstatin agents, appeared more than when nonstatin agents were prescribed alone. Among 70 159 statin users (91.0%), in-hospital mortality was 2.09% and unadjusted OR was 0.68 (95% CI, 0.64-0.72) relative to nontreated or late-treated patients. In comparison, among 6923 nonstatin users (9.0%), mortality was 2.50% and unadjusted OR was 0.81 (95% CI, 0.70-0.95) relative to nontreated or late-treated patients.

Finally, in a supplementary analysis, we considered all patients including the 2378 patients who died during the first hospital days. As with the primary analysis, use of lipid-lowering drugs was associated with a lower risk of in-hospital mortality (adjusted OR, 0.69; 95% CI, 0.65-0.73).

In this large observational study, we found that the administration of lipid-lowering agents during the early perioperative period was associated with a 1% absolute reduction of hospital mortality and a 38% reduction in the odds of in-hospital mortality among patients undergoing major noncardiac surgery who were matched for likelihood of treatment. Our findings suggest that lipid-lowering therapy may represent an important addition to the limited armamentarium of the perioperative consultant.

How might lipid-lowering medications produce the observed association in this study? It is well known that during long periods of administration these agents inhibit the development and progression of atherosclerosis.18 Additionally, in time frames as short as 4 to 8 weeks, statins have been shown to reduce platelet aggregation,19 improve endothelial dependent vasodilation,2022 and lower levels of C-reactive protein.23 These local and systemic effects may reduce plaque formation and stabilize existing plaques during periods of stress, such as are encountered around the time of major surgery.

Because our data were limited to the inpatient setting, we are unable to draw conclusions about how far in advance of surgery the medications might need to be started, if in fact the observed association is causal. Unlike β-blockade, the administration of lipid-lowering agents in the perioperative period is not the current standard of care, and it would be unusual to initiate such medications early during a hospital admission for a surgical procedure. The use of lipid-lowering medications observed in this study therefore most likely represented the continuation of a patient's outpatient regimen, but we did not know how far in advance of surgery lipid-lowering therapy was started.

Only 1 study has previously addressed the topic of lipid-lowering therapy in surgical patients. Poldermans et al24 performed a case-control study among 2816 patients who underwent major vascular surgery during a 10-year period at a single medical center in The Netherlands to examine the association between statin use and perioperative mortality. They found an adjusted OR for perioperative mortality among statin users of 0.22 (95% CI, 0.10-0.47). Although similar, our findings extend this analysis to multiple procedure types and drug classes using a multicenter cohort design.

Strengths of our study include its large size, national scope, and our use of a previously validated risk stratification tool. We focused on an important outcome, in-hospital mortality, and used both multivariable logistic regression and propensity analysis to adjust for a wide variety of potential confounders, including a large number of medications.

Our findings should nevertheless be interpreted with caution. First, this was an observational study that relied on administrative data based on physician documentation and coding to determine the presence of comorbidities that were later used to compare and adjust for differences between groups. It is possible that patients treated with lipid-lowering medications were in fact healthier than their untreated counterparts even though they were older and appeared to have a greater number of comorbidities. While acknowledging this potential bias, our results persisted in a propensity matched cohort that was balanced for many of these factors. Second, perioperative administration of lipid-lowering medications may simply be a marker of high-quality perioperative care in general, or more documentation of comorbidities. We observed more use of perioperative β-blockers as well as measures to prevent venous thromboembolism among those patients treated with lipid-lowering medications. Although we adjusted for these known differences, it is possible that unmeasured confounding related to physician practice remains unaccounted for in our analyses. Third, we were unable to determine how often patients taking lipid-lowering agents in the outpatient setting had their medications acutely discontinued during the hospitalization and whether this may have had any adverse consequences on their postoperative course. Moreover, it is possible that lipid-lowering medications may have been withheld precisely because the patients were too sick to resume treatment following surgery. To minimize confounding resulting from the misclassification of patients who may have been too ill to resume lipid-lowering therapy in the early postoperative period, we limited our study to patients who survived the first 2 days and we included other orally administered medications in our matching strategy. Fourth, we did not have access to laboratory results, such as serum cholesterol or C-reactive protein levels, and thus were unable to examine whether the benefits we observed were associated with levels of either of these markers. Similarly, we did not have reliable information concerning smoking status or left ventricular function. Lastly, our findings are limited by the lack of information on rates of postoperative cardiovascular complications, such as myocardial infarction or heart failure, which cannot be reliably obtained from administrative databases.25

The use of lipid-lowering medications in the perioperative period is associated with reduced mortality among patients undergoing major noncardiac surgery. Clinical trials are required to confirm this observation and to determine the optimal timing and duration of therapy.

Hall MJ, Owings MF. 2000 National Hospital Discharge Survey: Advance Data From Vital and Health Statistics, No. 329. Hyattsville, Md: National Center for Health Statistics; 2002.
Mangano DT. Perioperative cardiac morbidity.  Anesthesiology.1990;72:153-184.
PubMed
Nettleman MD, Banitt L, Barry W, Awan I, Gordon EEI. Predictors of survival and the role of gender in postoperative myocardial infarction.  Am J Med.1997;103:357-362.
PubMed
Lindenauer PK, Fitzgerald J, Hoople N, Benjamin EM. The potential preventability of postoperative myocardial infarction: underuse of perioperative β-adrenergic blockade.  Arch Intern Med.2004;164:762-766.
Lee TH, Marcantonio ER, Mangione C.  et al.  Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.  Circulation.1999;100:1043-1049.
PubMed
Poldermans D, Boersma E, Bax JJ.  et al.  The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery.  N Engl J Med.1999;341:1789-1794.
PubMed
Goldman L, Caldera DL, Nussbaum SR.  et al.  Multifactorial index of cardiac risk in noncardiac surgical procedures.  N Engl J Med.1977;297:845-850.
PubMed
Detsky AS, Abrams HB, Forbath N, Scott JG, Hilliard JR. Cardiac assessment for patients undergoing noncardiac surgery: a multifactorial clinical risk index.  Arch Intern Med.1986;146:2131-2134.
PubMed
Eagle KA, Coley CM, Newell JB.  et al.  Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery.  Ann Intern Med.1989;110:859-866.
PubMed
Sonksen J, Gray R, Hickman PH. Safer non-cardiac surgery for patients with coronary artery disease: medical treatment should be optimised to improve outcome.  BMJ.1998;317:1400-1401.
PubMed
Auerbach AD, Goldman L. Beta-blockers and reduction of cardiac events in noncardiac surgery: scientific review.  JAMA.2002;287:1435-1444.
PubMed
Shojania KG, Duncan BW, McDonald KM, Wachter RM. Making Health Care Safer: A Critical Analysis of Patient Safety PracticesRockville, Md: Agency for Healthcare Research and Quality; 2001. Evidence Report/Technology Assessment 43; AHRQ publication 01-E058.
Mangano DT, Layug EL, Wallace A, Tateo I.Multicenter Study of Perioperative Ischemia Research Group.  Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery.  N Engl J Med.1996;335:1713-1720. [published correction appears in N Engl J Med.1997;336:1039].
PubMed
Boersma E, Poldermans D, Bax JJ.  et al.  Predictors of cardiac events after major vascular surgery: role of clinical characteristics, dobutamine echocardiography, and β-blocker therapy.  JAMA.2001;285:1865-1873.
PubMed
Farmer JA. Pleiotropic effects of statins.  Curr Atheroscler Rep.2000;2:208-217.
PubMed
Dawood MM, Gutpa DK, Southern J, Walia A, Atkinson JB, Eagle KA. Pathology of fatal perioperative myocardial infarction: implications regarding pathophysiology and prevention.  Int J Cardiol.1996;57:37-44.
PubMed
Hosmer DW, Lemeshow S. Applied Logistic Regression. 2nd ed. Hoboken, NJ: John Wiley & Sons; 2000.
PubMed
Nissen SE, Tuzcu EM, Schoenhagen P.  et al. for the REVERSAL investigators.  Effect of intensive compared with moderate lipid-lowering therapy on progression of coronary atherosclerosis: a randomized controlled trial.  JAMA.2004;291:1071-1080.
PubMed
Osamah H, Mira R, Sorina S.  et al.  Reduced platelet aggregation after fluvastatin therapy is associated with altered platelet lipid composition and drug binding to the platelets.  Br J Clin Pharmacol.1997;44:77-83.
PubMed
Dupuis J, Tardif JC, Cernacek E, Theroux P. Cholesterol reduction rapidly improves endothelial function after acute coronary syndromes.  Circulation.1999;99:3227-3233.
PubMed
O'Driscoll G, Green D, Taylor RR. Simvastatin, an HMG-coenzyme A reductase inhibitor, improves endothelial function within 1 month.  Circulation.1997;95:1126-1131.
PubMed
Huggins GS, Pasternak RC, Alpert NM, Fischman AJ, Gewirtz H. Effects of short-term treatment of hyperlipidemia on coronary vasodilator function and myocardial perfusion in regions having substantial impairment of baseline dilator reserve.  Circulation.1998;98:1291-1296.
PubMed
Ridker PM, Rifai N, Lowenthal SP. Rapid reduction in C-reactive protein with cerivastatin among 785 patients with primary hypercholesterolemia.  Circulation.2001;103:1191-1193.
PubMed
Poldermans D, Bax JJ, Kertai MD.  et al.  Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac vascular surgery.  Circulation.2003;107:1848-1851.
PubMed
Best WR, Khuri SF, Phelan M.  et al.  Identifying patient preoperative risk factors and postoperative adverse events in administrative databases: results from the Department of Veterans Affairs National Surgical Quality Improvement Program.  J Am Coll Surg.2002;194:257-266.
PubMed

Figures

Figure 1. In-Hospital Mortality Associated With Lipid-Lowering Therapy in Propensity Based Quintiles
Graphic Jump Location
Error bars indicate 95% confidence intervals. Seventeen patients (0.002%) were excluded from multivariable analysis due to missing data; therefore, among 780 574 patients, mean lipid-lowering therapy use per quintile of propensity was 0.5% (quintile 1, n = 156 114), 1.9% (quintile 2, n = 156 115), 9.8% (quintile 3, n = 156 115), 10.9% (quintile 4, n = 156 115), and 31.3% (quintile 5, n = 156 115).
Figure 2. Adjusted Odds Ratios of In-Hospital Mortality Associated With Lipid-Lowering Therapy Stratified by Quintile of Propensity
Graphic Jump Location
Seventeen patients (0.002%) were excluded from multivariable analysis due to missing data; therefore, among 780 574 patients, mean lipid-lowering therapy use per quintile of propensity was 0.5% (quintile 1, n = 156 114), 1.9% (quintile 2, n = 156 115), 9.8% (quintile 3, n = 156 115), 10.9% (quintile 4, n = 156 115), and 31.3% (quintile 5, n = 156 115).

Tables

Table Graphic Jump LocationTable 1. Demographic and Clinical Characteristics of Patients Undergoing Major Noncardiac Surgery*
Table Graphic Jump LocationTable 2. Administrative Characteristics of Patients Undergoing Major Noncardiac Surgery and Mortality Rate*
Table Graphic Jump LocationTable 3. Characteristics of Hospitals Participating in Study
Table Graphic Jump LocationTable 4. Demographic and Clinical Characteristics of Patients Who Did or Did Not Receive Lipid-Lowering Therapy in Propensity Matched Cohort*
Table Graphic Jump LocationTable 5. Administrative Characteristics of Patients Who Did or Did Not Receive Lipid-Lowering Therapy in Propensity Matched Cohort and Mortality Rate
Table Graphic Jump LocationTable 6. Odds Ratio of In-Hospital Mortality Associated With Perioperative Lipid-Lowering Therapy
Table Graphic Jump LocationTable 7. Number Needed to Treat in Propensity Matched Cohort by Revised Cardiac Risk Index Score

References

Hall MJ, Owings MF. 2000 National Hospital Discharge Survey: Advance Data From Vital and Health Statistics, No. 329. Hyattsville, Md: National Center for Health Statistics; 2002.
Mangano DT. Perioperative cardiac morbidity.  Anesthesiology.1990;72:153-184.
PubMed
Nettleman MD, Banitt L, Barry W, Awan I, Gordon EEI. Predictors of survival and the role of gender in postoperative myocardial infarction.  Am J Med.1997;103:357-362.
PubMed
Lindenauer PK, Fitzgerald J, Hoople N, Benjamin EM. The potential preventability of postoperative myocardial infarction: underuse of perioperative β-adrenergic blockade.  Arch Intern Med.2004;164:762-766.
Lee TH, Marcantonio ER, Mangione C.  et al.  Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.  Circulation.1999;100:1043-1049.
PubMed
Poldermans D, Boersma E, Bax JJ.  et al.  The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery.  N Engl J Med.1999;341:1789-1794.
PubMed
Goldman L, Caldera DL, Nussbaum SR.  et al.  Multifactorial index of cardiac risk in noncardiac surgical procedures.  N Engl J Med.1977;297:845-850.
PubMed
Detsky AS, Abrams HB, Forbath N, Scott JG, Hilliard JR. Cardiac assessment for patients undergoing noncardiac surgery: a multifactorial clinical risk index.  Arch Intern Med.1986;146:2131-2134.
PubMed
Eagle KA, Coley CM, Newell JB.  et al.  Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery.  Ann Intern Med.1989;110:859-866.
PubMed
Sonksen J, Gray R, Hickman PH. Safer non-cardiac surgery for patients with coronary artery disease: medical treatment should be optimised to improve outcome.  BMJ.1998;317:1400-1401.
PubMed
Auerbach AD, Goldman L. Beta-blockers and reduction of cardiac events in noncardiac surgery: scientific review.  JAMA.2002;287:1435-1444.
PubMed
Shojania KG, Duncan BW, McDonald KM, Wachter RM. Making Health Care Safer: A Critical Analysis of Patient Safety PracticesRockville, Md: Agency for Healthcare Research and Quality; 2001. Evidence Report/Technology Assessment 43; AHRQ publication 01-E058.
Mangano DT, Layug EL, Wallace A, Tateo I.Multicenter Study of Perioperative Ischemia Research Group.  Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery.  N Engl J Med.1996;335:1713-1720. [published correction appears in N Engl J Med.1997;336:1039].
PubMed
Boersma E, Poldermans D, Bax JJ.  et al.  Predictors of cardiac events after major vascular surgery: role of clinical characteristics, dobutamine echocardiography, and β-blocker therapy.  JAMA.2001;285:1865-1873.
PubMed
Farmer JA. Pleiotropic effects of statins.  Curr Atheroscler Rep.2000;2:208-217.
PubMed
Dawood MM, Gutpa DK, Southern J, Walia A, Atkinson JB, Eagle KA. Pathology of fatal perioperative myocardial infarction: implications regarding pathophysiology and prevention.  Int J Cardiol.1996;57:37-44.
PubMed
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