Download

Letter to the Editor

Resident Physician Island Health - Vancouver Island Health Authority

Daniel Esau

Author for correspondence: Daniel Esau:

Submitted: 24 May 2021. Accepted 7 June 2021. Published: XX July 2021.

DOI: https://doi.org/10.22374/cjgim.v16i3.563

In the perioperative medicine special issue, Borges et al.1 discussed aspects of myocardial injury after noncardiac surgery (MINS) care and recommend initiating aspirin (ASA) and moderate-to-high dose statin in all patients diagnosed with MINS. One aspect of MINS management that was undiscussed in the article was patients in whom MINS management might be different, such as patients on dialysis. Borges et al.1 are not alone in this regard: the Canadian Cardiovascular Society (CCS) perioperative guidelines do not mention any specific exclusions for the initiation of ASA and statin in patients diagnosed with MINS.2 However, there is insufficient evidence to recommend ASA and statins in all patients with MINS, as exemplified by patients requiring dialysis.

The studies cited by the CCS perioperative guidelines (and Borges et al.1) as evidence for statin and ASA use in MINS patients examined perioperative MI, which only comprises a small portion of MINS diagnoses. Furthermore, these studies had limited enrollment of dialysis patients: the study by Devereaux et al.3 had 4.8% of patients with a creatinine level of higher than 175 μmol/L (the number of dialysis patients was not reported), and the study by Foucrier et al.4 reported that only 1.2% of enrolled patients were on dialysis. In the MANAGE trial, patients who had an estimated glomerular filtration rate (eGFR) of less than 35 mL/min that persisted for 35 days after suffering MINS were excluded, which would exclude chronic dialysis patients. In the VISION trial, only 3.6% of patients had an eGFR < 30 mL/min/1.73 m2 or were on dialysis.

Current KDIGO guidelines recommend not initiating statin therapy in patients on dialysis because of a lack of evidence of benefit.5 Although some evidence exists for statin therapy in dialysis patients presenting with the acute coronary syndrome, their use in primary prevention of coronary artery disease is controversial.6 There has not yet been a study, to my knowledge, specifically examining the initiation of statin and ASA in MINS patients who have postoperative ischemic troponin elevation without any ischemic features (i.e., without ischemic symptoms or electrocardiographic findings), which comprised around 78% of MINS patients in the VISION trial.7 It seems prudent, therefore, not to extend a recommendation for statin therapy to patients receiving dialysis presented with MINS, especially in those without ischemic features.

Given that few dialysis patients were included in the trials mentioned above, and there is little evidence for the initiation of statins in patients receiving dialysis, could the authors comment on whether dialysis patients (or other subgroups of patients) should be managed differently compared with the general postsurgical population.

References

1. Borges F, Ofori S, Marcucci M. Myocardial injury after noncardiac surgery and perioperative atrial fibrillation. Can J Gen Intern Med 2021;16(SP1):18–26.

2. Duceppe E, Parlow J, Macdonald P, et al. Canadian Cardiovascular Society Guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery. Can J Cardiol 2017;33(1):17–32.

3. Devereaux PJ, Xavier D, Pogue J, et al. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery. Ann Intern Med 2011;154(8):523–8.

4. Foucrier A, Rodseth R, Aissaoui M, et al. The long-term impact of early cardiovascular therapy intensification for postoperative troponin elevation after major vascular surgery. Anesth Analg 2014;119(5):1053–63.

5. Tonelli M, Wanner C, Kidney disease: Improving Global Outcomes Lipid Guideline Development Work Group M. Lipid management in chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2013 clinical practice guideline. Ann Intern Med 2014;160(3):182–9.

6. Washam JB, Herzog CA, Beitelshees AL, et al. Pharmacotherapy in chronic kidney disease patients presenting with acute coronary syndrome. Circulation. 2015;131(12):1123–49.

7. Devereaux PJ, Biccard BM, Sigamani A, et al. Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2017;317(16):1642.