In This Edition
- Perioperative smoking cessation reduces postoperative complications.
- Quality of life is not diminished in heart failure patients receiving defibrillator therapy.
- Simplification of the revised Geneva score may be useful in assessing for pulmonary embolism.
- Non-cardiac surgery after drug eluting stents not associated with major cardiac risk.
- Major cardiac risk is lowest 90 days after bare metal stent percutaneous coronary intervention.
- Extensive cancer screening in unexplained VTE detects more malignancies, but does not affect cancer related mortality.
- Preadmission use of statins decreases after hospitalization mortality in pneumonia.
- Drug-eluting stents are better than bare-metal stents for PCI in acute MI, but additional randomized study is needed.
Does a short duration of perioperative smoking cessation lead to a reduction in postoperative complications?
Background: Prior studies have demonstrated a reduction in postoperative complications when patients stop smoking in the perioperative period. However, they have not clearly shown what effect a fairly short duration of cessation, such as a period of only four weeks, has on the frequency of complications.
Study design: Randomized controlled trial.
Setting: Four university-affiliated hospitals in Sweden.
Synopsis: Using 117 patients who were daily smokers for less than one year between the ages of 18-79 who were scheduled for elective general or orthopedic surgery, this study showed that a smoking-cessation intervention initiated as little as four weeks prior to surgery resulted in fewer postoperative complications. The complication rate was reduced from 41% in the control group to 21% in the intervention group, which received cessation counseling and nicotine-replacement therapy. The relative risk reduction was 49% (95% confidence interval, 3-40) with a number needed to treat of five.
Because this was a randomized controlled trial with a large observed benefit, it appears to be reasonable to endorse perioperative smoking cessation as late as four weeks before an elective surgery. The study was limited in its ability to detect a difference in wound infections by the small sample size and the possibility patients might have unblinded themselves to outcome assessors, causing an overestimation of the effect of the intervention on the primary outcome of all complications.
Bottom line: Perioperative smoking cessation reduces postoperative complications even when started just four weeks prior to surgery.
Citation: Lindstrom D, Azodi OS, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications. Ann Surg. 2008;248(5):739-745.
Does implantable-defibrillator therapy cause deterioration in quality of life for patients with heart failure?
Background: Patients with depressed left-ventricular function are known to have improved survival after receiving implantable cardioverter defibrillators (ICDs). However, there is concern ICD therapy can prolong survival at the expense of a diminished quality of life.
Study design: Randomized placebo-controlled trial.
Setting: Multiple centers in the U.S., Canada, and New Zealand.
Synopsis: Using 2,479 patients from the Sudden Cardiac Death in Heart Failure trial who were 18 and older and had stable heart failure and depressed left-ventricular function, this study demonstrated no significant quality-of-life difference at 30 months when compared with patients who received ICD, amiodarone, and state-of-the-art medical therapy or an amiodarone placebo and state-of-the-art medical therapy. While functional status did not differ at any time between the three groups, psychological well-being was improved in the ICD group at three months (p=0.01) and 12 months (p=0.03) when compared with the placebo group, but at 30 months there was no difference between the groups.
While the trial was randomized and placebo-controlled, the investigators were unable to blind patients or outcome assessors. Nevertheless, the lack of deterioration of quality of life in ICD patients is reassuring.