Long-term incidence of myocardial infarct, stroke, and mortality in patients operated on for abdominal aortic aneurysms

Eldrup, Nikolaj; Budtz-Lilly, Jacob; Laustsen, Jesper; Bibby, Bo Martin; Paaske, William P.

doi:10.1016/j.jvs.2011.08.046

Cited by 40 publications

(29 citation statements)

References 36 publications

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“…118,119,121,122 Our finding that statins and antiplatelet therapy improve long-term survival emphasises the importance of these medications in the prevention of late cardiovascular events. 123 That statin use is associated with improved long-term survival is in keeping with previously published reports.…”

Section: Survival Modellingsupporting

confidence: 85%

Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation

Grant

Sperrin

Carlson

et al. 2015

Health Technology Assessment

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BackgroundAbdominal aortic aneurysm (AAA) repair aims to prevent premature death from AAA rupture. Elective repair is currently recommended when AAA diameter reaches 5.5 cm (men) and 5.0 cm (women). Applying population-based indications may not be appropriate for individual patient decisions, as the optimal indication is likely to differ between patients based on age and comorbidities.ObjectiveTo develop an Aneurysm Repair Decision Aid (ARDA) to indicate when elective AAA repair optimises survival for individual patients and to assess the cost-effectiveness and associated uncertainty of elective repair at the aneurysm diameter recommended by the ARDA compared with current practice.Data sourcesThe UK Vascular Governance North West and National Vascular Database provided individual patient data to develop predictive models for perioperative mortality and survival. Data from published literature were used to model AAA growth and risk of rupture. The cost-effectiveness analysis used data from published literature and from local and national databases.MethodsA combination of systematic review methods and clinical registries were used to provide data to populate models and inform the structure of the ARDA. Discrete event simulation (DES) was used to model the patient journey from diagnosis to death and synthesised data were used to estimate patient outcomes and costs for elective repair at alternative aneurysm diameters. Eight patient clinical scenarios (vignettes) were used as exemplars. The DES structure was validated by clinical and statistical experts. The economic evaluation estimated costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) from the NHS, social care provider and patient perspective over a lifetime horizon. Cost-effectiveness acceptability analyses and probabilistic sensitivity analyses explored uncertainty in the data and the value for money of ARDA-based decisions. The ARDA outcome measures include perioperative mortality risk, annual risk of rupture, 1-, 5- and 10-year survival, postoperative long-term survival, median life expectancy and predicted time to current threshold for aneurysm repair. The primary economic measure was the ICER using the QALY as the measure of health benefit.ResultsThe analysis demonstrated it is feasible to build and run a complex clinical decision aid using DES. The model results support current guidelines for most vignettes but suggest that earlier repair may be effective in younger, fitter patients and ongoing surveillance may be effective in elderly patients with comorbidities. The model adds information to support decisions for patients with aneurysms outside current indications. The economic evaluation suggests that using the ARDA compared with current guidelines could be cost-effective but there is a high level of uncertainty.LimitationsLack of high-quality long-term data to populate all sections of the model meant that there is high uncertainty about the long-term clinical and economic consequences of repair. Modelling assumptions were necessary and the developed survival models require external validation.ConclusionsThe ARDA provides detailed information on the potential consequences of AAA repair or a decision not to repair that may be helpful to vascular surgeons and their patients in reaching informed decisions. Further research is required to reduce uncertainty about key data, including reintervention following AAA repair, and assess the acceptability and feasibility of the ARDA for use in routine clinical practice.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Survival Modellingsupporting

confidence: 85%

Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation

Grant

Sperrin

Carlson

et al. 2015

Health Technology Assessment

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“…1,6 Potentially underappreciated is that patients with AAA are also at increased risk for cardiovascular disease and mortality. 5 Medical management for patients with symptomatic PAD and known cardiac disease is well outlined and endorsed by several multidisciplinary guidelines. 1,6,10,12 This treatment includes the use of AP and statin agents to reduce the incidence of cardiovascular events in addition to glucose control in diabetics, smoking cessation, and blood pressure control.…”

Section: Discussionmentioning

confidence: 99%

“…3 This results in a high incidence of clinical coronary and cerebrovascular disease among those with PAD and AAA. 1,4 Patients with AAA have a two-fold higher risk of heart attack and 1.8-fold higher risk of stroke compared with population-based controls, 5 and approximately 75% of those with PAD will ultimately die from cardiovascular causes. 1,6 …”

mentioning

confidence: 99%

Perioperative management with antiplatelet and statin medication is associated with reduced mortality following vascular surgery

Martino

Eldrup-Jørgensen

Nolan

et al. 2014

Journal of Vascular Surgery

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Objective Many patients undergoing vascular surgical procedures are not on appropriate medical therapy. This study sought to examine the variation and impact of antiplatelet (AP) and statin therapy on early and late mortality in patients undergoing vascular surgery in our region. Methods We studied all patients (n = 14,489) undergoing elective carotid endarterectomy (n = 6978), carotid stenting (n = 524), and suprainguinal (n = 763) and infrainguinal bypass (n = 3053), as well as patients with known coronary risk factors undergoing open (n = 1044) and endovascular (n = 2127) abdominal aortic aneurysm repair from 2005 to 2012 in the Vascular Study Group of New England. Optimal medical management was defined as treatment with both AP and statin agents, preoperatively and at discharge. We analyzed temporal, procedural, and center variation of medication use. Multivariable analyses were used to determine the adjusted impact of AP and statin therapy on 30-day mortality and 5-year survival. Results Optimal medical management improved over the study interval (55% in 2005 to 68% in 2012; P trend < .01) with carotid interventions having the highest rates of optimal medications use (carotid artery stenting, 78%; carotid endarterectomy, 74%) and abdominal aortic aneurysm repair in patients with known cardiac risk factors having the lowest (open, 57%; endovascular aneurysm repair, 56%). Optimal medication use varied by center as well (range, 40%-86%). Preoperative AP and statin use was associated with reduced 30-day mortality (odds ratio, 0.76; 95% confidence interval [CI], 0.5-1.05; P = .09). AP and statin prescription at discharge was additive in survival benefit with improved 5-year survival (hazard ratio, 0.5; 95% CI, 0.4-0.7; P< .01) that was consistent across procedure types. Patients prescribed AP and statin at discharge had 5-year survival of 79% (95% CI, 77%-81%) compared with only 61% (95% CI, 52%-68%; P< .001) for patients on neither medication. Conclusions AP and statin therapy preoperatively and at discharge was associated with reduced 30-day mortality and an absolute 18% improved 5-year survival after vascular surgery. However, one-third of patients are suboptimally managed in real world practice. This demonstrates an opportunity for quality improvement that can substantially improve survival after vascular surgery.

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“…Eine dänische Populationsstudie konnte zeigen, dass selbst nach erfolgreicher Behandlung des Aneurysmas das Risiko für einen Myokardinfarkt bei diesen Patienten ca. doppelt so hoch ist wie in der Allgemeinbevölkerung (Inzidenz 2,5 % gegenüber 1,1 %; [9]). …”

Section: Kardiovaskuläre Und Zerebrale Komplikationenunclassified

“…[OR] 6,3), rupturiertes Aortenaneurysma (OR 3,2), Ligatur einer oder beider A. iliaca interna (OR 2,6), aber auch die Operation in Low-volume-Krankenhäusern (OR 1,9). Zudem steigt die Hazard Ratio parallel zu steigendem Alter des Patienten und zunehmender Aortenklemmzeit bzw.…”

Section: Kolonischämie Und Ischämien Der Beckenorganeunclassified

Komplikationen nach Rekonstruktion der Aorta

Kleinspehn¹,

Heidemann²,

Behrendt³

et al. 2015

Chirurg

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Long-term incidence of myocardial infarct, stroke, and mortality in patients operated on for abdominal aortic aneurysms

Abstract: AAA patients of both sexes have a high risk of atherosclerotic events (MI, stroke) and death, so lifelong prophylaxis must be considered from our epidemiologic data. Randomized trials investigating the potential benefit of aspirin and statin therapy in AAA patients are needed.

Cited by 40 publications

References 36 publications

Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation

Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation

Perioperative management with antiplatelet and statin medication is associated with reduced mortality following vascular surgery

Komplikationen nach Rekonstruktion der Aorta

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