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Commentary: Inattention to detail is the hallmark of mediocrity

  • Julia Benk
    Correspondence
    Address for reprints: Julia Benk, MD, Department of Cardiovascular Surgery, University Heart Center, University Hospital Freiburg, Hugstetter Str 55, D-79106, Freiburg im Breisgau, Germany.
    Affiliations
    Department of Cardiovascular Surgery, University Heart Center, University Hospital Freiburg, Freiburg, Germany

    Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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  • Friedhelm Beyersdorf
    Affiliations
    Department of Cardiovascular Surgery, University Heart Center, University Hospital Freiburg, Freiburg, Germany

    Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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Published:September 18, 2021DOI:https://doi.org/10.1016/j.jtcvs.2021.09.026
      Figure thumbnail fx1
      Julia Benk, MD, and Friedhelm Beyersdorf, MD
      Results after coronary artery bypass graft surgery are affected by the surgical procedure and the secondary prevention; therefore, postoperative medication (especially statins) is fundamental.
      See Article page 1875.
      Coronary artery bypass graft (CABG) surgery has undergone several innovative phases over the last number of decades. These include, for example, off-pump surgery, total arterial bypass grafting and minimally invasive approaches, sophisticated surgical techniques for the anastomoses, improved myocardial protection techniques, as well as improvements in the technology of extracorporeal circulation. These advances have improved the results in terms of mortality and morbidity perceivably.
      • Sousa-Uva M.
      • Neumann F.J.
      • Ahlsson A.
      • Alfonso F.
      • Banning A.P.
      • Benedetto U.
      • et al.
      2018 ESC/EACTS guidelines on myocardial revascularization.
      ,
      • Hillis L.D.
      • Smith P.K.
      • Anderson J.L.
      • Bittl J.A.
      • Bridges C.R.
      • Byrne J.G.
      • et al.
      2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines.
      However, postoperative management is just as important as the surgical techniques, especially for the long-term outcome. Several papers have been published showing the importance of postoperative pharmacologic strategies for improved long-term survival, which recommend β-blockers, renin–angiotensin–aldosterone system inhibitors, platelet inhibitors, and statins.
      • Sousa-Uva M.
      • Neumann F.J.
      • Ahlsson A.
      • Alfonso F.
      • Banning A.P.
      • Benedetto U.
      • et al.
      2018 ESC/EACTS guidelines on myocardial revascularization.
      • Hillis L.D.
      • Smith P.K.
      • Anderson J.L.
      • Bittl J.A.
      • Bridges C.R.
      • Byrne J.G.
      • et al.
      2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines.
      • Sousa-Uva M.
      • Head S.J.
      • Milojevic M.
      • Collet J.P.
      • Landoni G.
      • Castella M.
      • et al.
      2017 EACTS guidelines on perioperative medication in adult cardiac surgery.
      While strict postoperative medication plans are used for the majority of patients with coronary artery disease after interventional treatments, this is rarely the case after CABG.
      The present study
      • Pan E.
      • Nielsen S.J.
      • Mennander A.
      • Björklund E.
      • Martinsson A.
      • Lindgren M.
      • et al.
      Statins for secondary prevention and major adverse events after coronary artery bypass grafting.
      is extremely important to highlight once again the imperative necessity of postoperative medication in the long term. This very unique study, in which data are generated from 5 mandatory national registries and merged for the study (ie, Swedish Cardiac Surgery Registry, National Patient Register, National Cause of Death Register, Swedish Population Register, and Swedish Prescribed Drug Register), uses the unique identification number allocated to all Swedish residents.
      In fact, the study found that ongoing statin treatment was associated with a reduced risk for all of the investigated outcome variables. Patients often fear stroke and dementia as much as death; therefore, many other factors other than mortality are of importance. Previous studies have shown that younger, but not older, patients undergoing CABG have an increased risk of dementia in comparison with an aged- and sex-matched control population.
      • Giang K.W.
      • Jeppsson A.
      • Karlsson M.
      • Hansson E.C.
      • Pivodic A.
      • Skoog I.
      • et al.
      The risk of dementia after coronary artery bypass grafting in relation to age and sex.
      The present study shows a significant correlation between the ongoing use of statins and a reduced risk of dementia (adjusted hazard ratio, 0.75), which could motivate patients and doctors to continue with statins, even for a long time after surgery. The main reason for discontinuing the medication with statins may be the relatively high incidence of side effects, such as statin-associated muscle symptoms or central nervous system complaints. For instance, up to 10% of the patients using statins complain of aching muscles. In these patients, it is essential to change to another effective lipid-lowering therapy. Fortunately, severe symptoms like rhabdomyolysis are rare.
      • Thompson P.D.
      • Panza G.
      • Zaleski A.
      • Taylor B.
      Statin-associated side effects.
      The strengths and limitations are very well presented in the manuscript. The strengths include the very large patient cohort, the real-world setting, the use of validated registries and databases, full national coverage, and no patient loss during follow-up. A particular strength is that time-updated dispense of medications was used in the statistical models. The main limitation is the observational study design with a risk of selection bias and residual confounding. There were also a number of patients on low-dose statins, which makes the comparison between different statin doses less reliable. Further limitations include the missing data on blood cholesterol levels and the reasons for discontinuing the medication.
      All in all, the authors are to be congratulated for this paper, which has the potential to provide the basis for further long-term improvements of CABG. Our surgical responsibility does not end with the perfect construction of coronary anastomoses, but continues with the postoperative care. As Michael E. DeBakey says, “Inattention to detail is the hallmark of mediocrity.”

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