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Biomedical subjects

Martin H Prins

Publications and source records attributed to Martin H Prins.

At least 19 recordsLinked to original sources
PubMed2006

Intraocular pressure-lowering effect of adding dorzolamide or latanoprost to timolol: a meta-analysis of randomized clinical trials.

OBJECTIVE: To estimate the intraocular pressure (IOP)-lowering effect of 2% dorzolamide or 0.005% latanoprost when added to 0.5% timolol. DESIGN: Meta-analysis of randomized clinical trials. PARTICIPANTS: Seventeen articles reporting on 19 study arms with 5 possible treatment combinations and 4 study arms serving as controls. METHODS: Articles written in English, German, French, or Dutch and published up to December 2004 were identified in Medline, Embase, the Cochrane Controlled Trials Register, and references from relevant articles. For the article to be considered, over 85% of the patients had to have primary open-angle glaucoma or ocular hypertension. The pooled 1- to 3-month additional IOP-lowering effect after a run-in phase on timolol was calculated by performing meta-analysis using the random effects model. MAIN OUTCOME MEASURES: Absolute and relative changes in IOP after run-in on timolol for peak moment, trough moment, or mean diurnal curve. RESULTS: The pooled change from baseline [mean (95% confidence interval)] for 0.5% timolol varied from -0.7 mmHg (-1.2 to -0.2, for the mean diurnal curve) to -2.0 mmHg (-1.3 to -2.7, at peak). Pooled changes for 2% dorzolamide in concomitant use with 0.5% timolol were -4.1 mmHg (-4.4 to -3.8) at trough and -4.9 mmHg (-5.3 to -4.5) at peak. The fixed 2% dorzolamide and 0.5% timolol combination resulted in a pooled change of -3.8 mmHg (-4.2 to -3.4) at trough and -4.9 mmHg (-5.3 to -4.5) at peak. The concomitant use of 0.005% latanoprost and 0.5% timolol gave a pooled change from baseline of -6.0 mmHg (-6.8 to -5.2) at the mean diurnal curve. The fixed combination of 0.005% latanoprost and 0.5% timolol resulted in a mean change of -3.0 mmHg (-3.8 to -2.2) at the mean diurnal curve. CONCLUSION: In this meta-analysis of clinical trials, the addition of dorzolamide or latanoprost further lowers IOP in eyes on timolol. This result may not be generalizable because these trials may have included nonresponders to timolol.

Antihypertensive Agents↗
PubMed2006

A prospective cohort study on the absolute incidence of venous thromboembolism and arterial cardiovascular disease in asymptomatic carriers of the prothrombin 20210A mutation.

The prothrombin 20210A mutation has been associated with an increased risk for venous thromboembolism (VTE) and arterial cardiovascular disease. The risks for asymptomatic carriers of this mutation have thus far been studied only in case-control and retrospective cohort studies. Here we present the results of the first prospective observational study in asymptomatic first-degree family members of patients with either VTE or premature atherosclerosis and the prothrombin 20210A mutation. We included 464 individuals (236 carriers) with a total follow-up duration of 1816 years (943 years for the carriers). The annual incidence of a first VTE was 0.37% (95% CI, 0.08-1.08) for carriers and 0.12% (95% CI, 0.00-0.69) for noncarriers (HR, 3.1; 95% CI, 0.3-29.6). The annual incidence of a first arterial cardiovascular event was 0.56% (95% CI, 0.18-1.31) for carriers and 0.73% (95% CI, 0.27-1.58) for noncarriers (adjusted HR, 0.7; 95% CI, 0.2-2.5). We conclude that the absolute incidence of a first VTE or arterial cardiovascular event is low; therefore, the clinical implications of carriership of the prothrombin 20210A mutation are limited, and routinely testing all first-degree relatives of probands with this mutation does not appear to be justified.

Adolescent↗
PubMed2006

Antithrombotic treatment in real-life atrial fibrillation patients: a report from the Euro Heart Survey on Atrial Fibrillation.

AIMS: To describe guideline adherence and application of different stroke risk stratification schemes regarding antithrombotic therapy in real-life atrial fibrillation (AF) patients and to assess which factors influence antithrombotic management decisions. METHODS AND RESULTS: The Euro Heart Survey enrolled 5333 AF patients in 35 countries, in 2003 and 2004. Prescription of antithrombotic drugs, especially oral anticoagulation (OAC), was hardly tailored to the patient's stroke risk profile as indicated by the joint guidelines of the American College of Cardiology, American Heart Association, and the European Society of Cardiology, ACCP guidelines, or CHADS(2) and Framingham risk scores. In multivariable analysis, only a limited number of the well-known stroke risk factors triggered OAC prescription. In contrast, less relevant factors, of which clinical type of AF and availability of an OAC monitoring outpatient clinic were the most marked, played a significant role in OAC prescription. Electrical cardioversions and catheter ablations clearly triggered OAC prescription, whereas pharmacological cardioversions even in the presence of stroke risk factors did not. CONCLUSION: Antithrombotic therapy in AF is hardly tailored to the patient's stroke risk profile. Factors other than well-known stroke risk factors were significantly involved in antithrombotic management decisions. To facilitate this tailored treatment, guideline writers and physician educators should focus on providing one uniform and easy to use stroke risk stratification scheme.

Adult↗
PubMed2006

Changes in glaucoma treatment and achieved IOP after introduction of new glaucoma medication.

PURPOSE: To describe changes in glaucoma treatment and achieved IOP (intraocular pressure) over the period 1995-2002, 4 years before and 4 years after new glaucoma drugs had become available (January 1999). METHODS: An observational study was conducted in primary open-angle glaucoma (suspect), and ocular hypertension patients (n=1561) who had started medical treatment in 1995 or thereafter. The processes of starting, changing and intensifying medical treatment in general, and in patients with contraindications to beta-blockers before and after January 1999 were described. The change in mean IOP and the percentage of patients achieving an intraocular pressure below 18 or 22 mmHg were calculated. RESULTS: After January 1999, a shift from starting on betaxolol to hypotensive lipids took place. This shift was more pronounced in patients with respiratory comorbidity. The percentage of patients starting on timolol did not differ between both periods. After January 1999, therapy was changed more often in the first two visits compared with the period before January 1999 (38% versus 27%, P<0.0001). In more recent years, a larger percentage of glaucoma patients were treated with two or more drugs (34% in 2002 versus 13% in 1995). Over the period 1995-2002, baseline IOP did not change (P=0.85); for mean IOP at visit 4, a trend to lower IOPs was observed (P<0.0001). More patients achieved an IOP level under 22 and 18 mmHg after January 1999 than before, 85% versus 77%, and 46% versus 33%, respectively (P<0.0001). CONCLUSIONS: This study shows a change in process of glaucoma treatment and lower achieved IOP after new glaucoma drugs had become available.

Adrenergic beta-Antagonists↗
PubMed2006

All that glisters is not gold: a comparison of electronic monitoring versus filled prescriptions--an observational study.

BACKGROUND: Poor compliance with antihypertensive medication is assumed to be an important reason for unsatisfactory control of blood pressure. Poor compliance is difficult to detect. Each method of measuring compliance has its own strengths and weaknesses. The aim of the present study was to compare patient compliance with antihypertensive drugs as measured by two methods, electronic monitoring versus refill compliance. METHODS: 161 patients with a diagnosis of hypertension for at least a year prior to inclusion, and inadequate blood pressure control (systolic blood pressure > or = 160 mmHg and/or diastolic blood pressure > or = 95 mmHg) despite the use of antihypertensive drugs, were included. Patients' pharmacy records from 12 months prior to inclusion were obtained. Refill compliance was calculated as the number of days for which the pills were prescribed divided by the total number of days in this period. After inclusion compliance was measured with an electronic monitor that records time and date of each opening of the pillbox. Agreement between both compliance measures was calculated using Spearman's correlation coefficient and Cohen's kappa coefficient. RESULTS: There was very little agreement between the two measures. Whereas refill compliance showed a large range of values, compliance as measured by electronic monitoring was high in almost all patients with estimates between 90% and 100%. Cohen's kappa coefficient was 0.005. CONCLUSION: While electronic monitoring is often considered to be the gold standard for compliance measurements, our results suggest that a short-term electronic monitoring period with the patient being aware of electronic monitoring is probably insufficient to obtain valid compliance data. We conclude that there is a strong need for more studies that explore the effect of electronic monitoring on patient's compliance.

Aged↗
PubMed2006

Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial.

OBJECTIVE: To determine the efficacy and safety of the anticoagulant fondaparinux in older acute medical inpatients at moderate to high risk of venous thromboembolism. DESIGN: Double blind randomised placebo controlled trial. SETTING: 35 centres in eight countries. PARTICIPANTS: 849 medical patients aged 60 or more admitted to hospital for congestive heart failure, acute respiratory illness in the presence of chronic lung disease, or acute infectious or inflammatory disease and expected to remain in bed for at least four days. INTERVENTIONS: 2.5 mg fondaparinux or placebo subcutaneously once daily for six to 14 days. OUTCOME MEASURE: The primary efficacy outcome was venous thromboembolism detected by routine bilateral venography along with symptomatic venous thromboembolism up to day 15. Secondary outcomes were bleeding and death. Patients were followed up at one month. RESULTS: 425 patients in the fondaparinux group and 414 patients in the placebo group were evaluable for safety analysis (10 were not treated). 644 patients (75.9%) were available for the primary efficacy analysis. Venous thrombembolism was detected in 5.6% (18/321) of patients treated with fondaparinux and 10.5% (34/323) of patients given placebo, a relative risk reduction of 46.7% (95% confidence interval 7.7% to 69.3%). Symptomatic venous thromboembolism occurred in five patients in the placebo group and none in the fondaparinux group (P = 0.029). Major bleeding occurred in one patient (0.2%) in each group. At the end of follow-up, 14 patients in the fondaparinux group (3.3%) and 25 in the placebo group (6.0%) had died. CONCLUSION: Fondaparinux is effective in the prevention of asymptomatic and symptomatic venous thromboembolic events in older acute medical patients. The frequency of major bleeding was similar for both fondaparinux and placebo treated patients.

Acute Disease↗
PubMed2006

Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography.

CONTEXT: Previous studies have evaluated the safety of relatively complex combinations of clinical decision rules and diagnostic tests in patients with suspected pulmonary embolism. OBJECTIVE: To assess the clinical effectiveness of a simplified algorithm using a dichotomized clinical decision rule, D-dimer testing, and computed tomography (CT) in patients with suspected pulmonary embolism. DESIGN, SETTING, AND PATIENTS: Prospective cohort study of consecutive patients with clinically suspected acute pulmonary embolism, conducted in 12 centers in the Netherlands from November 2002 through December 2004. The study population of 3306 patients included 82% outpatients and 57% women. INTERVENTIONS: Patients were categorized as "pulmonary embolism unlikely" or "pulmonary embolism likely" using a dichotomized version of the Wells clinical decision rule. Patients classified as unlikely had D-dimer testing, and pulmonary embolism was considered excluded if the D-dimer test result was normal. All other patients underwent CT, and pulmonary embolism was considered present or excluded based on the results. Anticoagulants were withheld from patients classified as excluded, and all patients were followed up for 3 months. MAIN OUTCOME MEASURE: Symptomatic or fatal venous thromboembolism (VTE) during 3-month follow-up. RESULTS: Pulmonary embolism was classified as unlikely in 2206 patients (66.7%). The combination of pulmonary embolism unlikely and a normal D-dimer test result occurred in 1057 patients (32.0%), of whom 1028 were not treated with anticoagulants; subsequent nonfatal VTE occurred in 5 patients (0.5% [95% confidence interval {CI}, 0.2%-1.1%]). Computed tomography showed pulmonary embolism in 674 patients (20.4%). Computed tomography excluded pulmonary embolism in 1505 patients, of whom 1436 patients were not treated with anticoagulants; in these patients the 3-month incidence of VTE was 1.3% (95% CI, 0.7%-2.0%). Pulmonary embolism was considered a possible cause of death in 7 patients after a negative CT scan (0.5% [95% CI, 0.2%-1.0%]). The algorithm was completed and allowed a management decision in 97.9% of patients. CONCLUSIONS: A diagnostic management strategy using a simple clinical decision rule, D-dimer testing, and CT is effective in the evaluation and management of patients with clinically suspected pulmonary embolism. Its use is associated with low risk for subsequent fatal and nonfatal VTE.

Adult↗
PubMed2006

Cost-effectiveness of Mohs Micrographic Surgery vs Surgical Excision for Basal Cell Carcinoma of the Face.

OBJECTIVE: To assess the cost-effectiveness of Mohs micrographic surgery (MMS) compared with the surgical excision for both primary and recurrent basal cell carcinoma (BCC). DESIGN: A cost-effectiveness study performed alongside a prospective randomized clinical trial in which MMS was compared with surgical excision. SETTING: The study was carried out from 1999 to 2002 at the dermatology outpatient clinic of the University Hospital Maastricht, Maastricht, The Netherlands. PARTICIPANTS: A total of 408 primary (374 patients) and 204 recurrent (191 patients) cases of facial BCC were included. MAIN OUTCOME MEASURES: The mean total treatment costs of MMS and surgical excision for both primary and recurrent BCC and the incremental cost-effectiveness ratio, calculated as the difference in costs between MMS and surgical excision divided by their difference in effectiveness. The resulting ratio is defined as the incremental costs of MMS compared with surgical excision to prevent 1 additional recurrence. RESULTS: Compared with surgical excision, the total treatment costs of MMS are significantly higher (cost difference: primary BCC, 254 euros; 95% confidence interval, 181-324 euros; recurrent BCC, 249 euros; 95% confidence interval, 175-323 euros). For primary BCC, the incremental cost-effectiveness ratio was 29,231 euros, while the ratio for recurrent BCC amounted to 8094 euros. The acceptability curves showed that for these ratios, the probability of MMS being more cost-effective than surgical excision never reached 50%. CONCLUSIONS: At present, it does not seem cost-effective to introduce MMS on a large scale for both primary and recurrent BCC. However, because a 5-year period is normally required to determine definite recurrence rates, it is possible that MMS may become a cost-effective treatment for recurrent BCC.

Aged↗
PubMed2006

Determinants of satisfaction with the health state of the facial skin in patients undergoing surgery for facial basal cell carcinoma.

OBJECTIVE: The main objective of the study was to assess which health beliefs predict and explain satisfaction with the facial health state of patients undergoing surgery for basal cell carcinoma. METHODS: Data were collected by administering a newly developed questionnaire pre-operatively and 6 months post-operatively (n = 222). RESULTS: Results show that satisfaction as measured by post-operative worrying, susceptibility and fear of developing a new BCC at other facial sites can be predicted by pre-operative health beliefs. In addition, some patients an increase in perceived susceptibility, fear of recurrence of BCC on the same site or fear of developing a new BCC at other facial sites. CONCLUSION: Our findings indicate that both pre- and post-operative perceptions predict and explain for a substantial part the extent to which patients are satisfied with their facial health state 6 months after surgery. PRACTICE IMPLICATIONS: Administering a short questionnaire at the start of the treatment period will give physicians a better understanding of how patients experience this skin disease. It will also help them to adjust information about BCC and its consequences to the needs of the patient.

Aged↗
PubMed2006

Does fast-track treatment lead to a decrease of intensive care unit and hospital length of stay in coronary artery bypass patients? A meta-regression of randomized clinical trials.

OBJECTIVE: Evaluation of randomized, controlled clinical trials studying fast-track treatment in low-risk coronary artery bypass grafting patients. DESIGN: Meta-regression. PATIENTS: Low-risk coronary artery bypass grafting patients. INTERVENTIONS: Fast-track treatments including (high or low) anesthetic dose, normothermia vs. hypothermia, and extubation protocol (within or after 8 hrs). MEASUREMENTS: Number of hours of intensive care unit stay, number of days of hospital stay, prevalence of myocardial infarction, and death. Furthermore, quality of life and cost evaluations were evaluated. The epidemiologic and economic qualities of the different trials were also assessed. MAIN RESULTS: A total of 27 studies evaluating fast-track treatment were identified, of which 12 studies were with major and 15 were without major differences in extubation protocol or anesthetic treatment or both. The use of an early extubation protocol (p=.000) but not the use of a low anesthetic dose (p=.394) or normothermic temperature management (p=.552) resulted in a decrease of the total intensive care unit stay of low-risk coronary artery bypass grafting patients. Early extubation was found to be an important determinant of the total hospital stay for these patients. An influence of the type of fast-track treatment on mortality or the prevalence of postoperative myocardial infarction was not observed. In general, the epidemiologic and economic qualities of included studies were moderate. CONCLUSIONS: Although fast-track anesthetics and normothermic temperature management facilitate early extubation, the introduction of an early extubation protocol seems essential to decrease intensive care unit and hospital stay in low-risk coronary artery bypass grafting patients.

Adolescent↗
PubMed2006

Symptomatic peripheral arterial disease: the value of a validated questionnaire and a clinical decision rule.

BACKGROUND: If a validated questionnaire, when applied to patients reporting with symptoms of intermittent claudication, could adequately discriminate between those with and without peripheral arterial disease, GPs could avoid the diagnostic measurement of the ankle brachial index. AIM: To investigate the Edinburgh Claudication Questionnaire (ECQ) in general practice and to develop a clinical decision rule based on risk factors to enable GPs to easily assess the likelihood of peripheral arterial disease. DESIGN OF STUDY: An observational study. SETTING: General practice in The Netherlands. METHOD: This observational study included patients of > or =55 years visiting their GP for symptoms suggestive of intermittent claudication or with one risk factor. The ECQ and the ankle brachial index were performed. The prevalence of peripheral arterial disease, defined as an ankle brachial index <0.9, was related to risk factors using logistic regression analyses, on which a clinical decision rule was developed and related to the presence of peripheral arterial disease. RESULTS: Of the 4790 included patients visiting their GP with symptoms suggestive of intermittent claudication, 4527 were eligible for analyses. The prevalence of peripheral arterial disease in this group was 48.3%. The sensitivity of the ECQ was only 56.2%. The prevalence of peripheral arterial disease in a clinical decision rule that included age, male sex, smoking, hypertension, hypercholesterolemia, and a positive ECQ, increased from 14% in the lowest to 76% in the highest category. CONCLUSION: This study indicates that the ECQ alone has an inadequate diagnostic value in detecting patients with peripheral arterial disease. The ankle brachial index should be performed to diagnose peripheral arterial disease in patients with complaints suggestive of intermittent claudication, although our clinical decision rule could help to differentiate between extremely high and lower prevalence of peripheral arterial disease.

Aged↗
PubMed2005

Atrial fibrillation management: a prospective survey in ESC member countries: the Euro Heart Survey on Atrial Fibrillation.

AIMS: To describe atrial fibrillation (AF) management in member countries of the European Society of Cardiology (ESC) and to verify cardiology practices against guidelines. METHODS AND RESULTS: Among 182 hospitals in 35 countries, 5333 ambulant and hospitalized AF patients were enrolled, in 2003 and 2004. AF was primary or secondary diagnosis, and was confirmed on ECG in the preceding 12 months. Clinical type of AF was reported to be first detected in 978, paroxysmal in 1517, persistent in 1167, and permanent in 1547 patients. Concomitant diseases were present in 90% of all patients, causing risk factors for stroke to be also highly prevalent (86%). As many as 69% of patients were symptomatic at the time of the survey; among asymptomatic patients, 54% were previously experienced symptoms. Oral anticoagulation was prescribed in 67 and 49% of eligible and ineligible patients, respectively. A rhythm control strategy was applied in 67% of currently symptomatic patients and in 44% of patients who never experienced symptoms. CONCLUSION: This survey provides a unique snapshot of current AF management in ESC member countries. Discordance between guidelines and practice was found regarding several issues on stroke prevention and antiarrhythmic therapy.

Adult↗
PubMed2005

Combined training of GPs and practice-assistants on peripheral arterial disease: positive effects after six months.

OBJECTIVES: To improve the use of the ankle-brachial index (ABI) measurement, and management of patients with peripheral arterial disease (PAD) a combined training, targeting GPs and practice assistants (PAs) was developed. To measure the effect of the combined training on the management of patients with PAD, a cross-sectional study was performed. METHODS: Fifty consecutive patients referred by GPs to a vascular surgery out-patient clinic were analysed. Six months after the training an additional fifty patients were included. In all patients the ABI measurement, risk factor management, and treatment as performed by the GP, prior to referral, were analysed. RESULTS: The measurement of the ABI significantly increased from 10% before the training to 53% after the training (GPs with training: 83%, GPs without training: 35%; P: 0.001). The referral of patients with actual PAD significantly increased from 32% before the training to 70% after the training (GPs with training: 83%, GPs without training: 59%; P: 0.05). The presence and treatment of risk factors did not differ between the groups. CONCLUSIONS: Within the limitations of a before and after study the combined training of GPs and PAs appears to be an effective method to increase ABI measurements and significantly improve adequate diagnostics.

Aged↗
PubMed2005

A review on the design and reporting of studies on drug-gene interaction.

OBJECTIVE: Methodological standards for clinical pharmacogenetic studies should be developed to improve reporting of studies and facilitate their inclusion in systematic reviews. The essence of these studies lies within the concept of effect modification. STUDY DESIGN AND SETTING: A narrative review discussing methodological issues in the design and reporting of pharmacogenetic studies. RESULTS: Studying effect modification within a trial leads to the comparison of subgroups based on genotype. Differences in effect based on genotype should preferably be expressed in absolute terms (risk differences) to facilitate clinical decisions on treatment. Information on the distribution of potential effect modifiers or prognostic factors should be available to prevent a biased comparison of differences in effect between genotypes. The distribution of genotypes should also be presented and compared to Hardy-Weinberg equilibrium to check for selection bias. Additional points of interest include the possibility of selective nonavailability of biomaterial and the choice of a statistical model to study effect modification. CONCLUSION: Additional methodological issues should be taken into account when designing and reporting pharmacogenetic studies, to ensure high study quality. We present several important issues for future studies investigating drug-gene interactions that can serve as a basis for further discussion on methodology in pharmacogenetics.

Genotype↗
PubMed2005

The effect of low molecular weight heparin on survival in patients with advanced malignancy.

PURPOSE: Studies in cancer patients with venous thromboembolism suggested that low molecular weight heparin may prolong survival. In a double-blind study, we evaluated the effect of low molecular weight heparin on survival in patients with advanced malignancy without venous thromboembolism. METHODS: Patients with metastasized or locally advanced solid tumors were randomly assigned to receive a 6-week course of subcutaneous nadroparin or placebo. The primary efficacy analysis was based on time from random assignment to death. The primary safety outcome was major bleeding. RESULTS: In total, 148 patients were allocated to nadroparin and 154 patients were allocated to placebo. Mean follow-up was 1 year. In the intention-to-treat analysis the overall hazard ratio of mortality was 0.75 (95% CI, 0.59 to 0.96) with a median survival of 8.0 months in the nadroparin recipients versus 6.6 months in the placebo group. After adjustment for potential confounders, the treatment effect remained statistically significant. Major bleeding occurred in five (3%) of nadroparin-treated patients and in one (1%) of the placebo recipients (P = .12). In the a priori specified subgroup of patients with a life expectancy of 6 months or more at enrollment, the hazard ratio was 0.64 (95% CI, 0.45 to 0.90) with a median survival of 15.4 and 9.4 months, respectively. For patients with a shorter life expectancy, the hazard ratio was 0.88 (95% CI, 0.62 to 1.25). CONCLUSION: A brief course of subcutaneous low molecular weight heparin favorably influences the survival in patients with advanced malignancy and deserves additional clinical evaluation.

Adult↗
PubMed2005

Guidelines were developed for data collection from medical records for use in retrospective analyses.

OBJECTIVE: To construct a set of guidelines for data collection from medical records. STUDY DESIGN AND SETTING: Retrospective analysis of clinical data is often performed by physician-scientists. In such research, the source of clinical data is the patient's medical record; however, medical records are intended for patient care and the data are not systematically recorded for research purposes. We drew on recommendations in the literature and our own experience with a retrospective cohort study that uses a DNA bank to construct guidelines for data collection from medical records. RESULTS: The guidelines incorporate a number of strategies for accurate data collection, which are discussed and illustrated by application. CONCLUSION: With guidelines for data collection, the quality of research data is enhanced. A well-designed case record form and a handbook for standardized data collection are essential for training the data collectors and for ensuring fastidious searching of the record; however, certain kinds of information are not always well documented in patient records. Consequently, it is essential to perform a pilot study to assess the study design and to use additional questionnaires. Correct interpretation of clinical outcomes documented in the medical records often necessitates an independent adjudication committee to prevent bias in outcome definition.

Bias↗
PubMed2005

Smoking and the patency of lower extremity bypass grafts: a meta-analysis.

OBJECTIVE: Smoking is the major risk factor associated with the development and progression of peripheral arterial disease (PAD). To establish the best estimate of the effect of smoking, smoking cessation, and the dose-response relationship on the patency of lower extremity bypass grafts, we performed a systematic review. METHODS: A search of medical articles and reviews relating to the influence of smoking on the patency of arterial reconstructive grafts in patients with PAD was made. Studies considered for inclusion were those that evaluated the influence of smoking on the primary, secondary, or cumulative patency rates of arterial reconstructive surgery in the lower extremities in patients with PAD. Primary data were used to calculate summary estimates with standard meta-analysis techniques. RESULTS: The 29 eligible studies included 4 randomized clinical trials, 12 prospective studies, and 13 retrospective studies. The effect of smoking on graft patency in the randomized clinical trials and other prospective studies had a 3.09-fold (2.34 to 4.08; P < .00001) increase in graft failure. A comparison of patency rates among all studies that used autogenous or polyester grafts showed no difference. A clear dose-response relationship was present, with a decreased patency in heavy smokers compared with moderate smokers. Smoking cessation restores patency rates toward the never smokers group. CONCLUSION: Continued smoking after lower limb bypass surgery results in a threefold increased risk of graft failure. Smoking cessation, even if instigated after the operation, restored graft patency towards the patency of never smokers. These results indicate that adequate smoking cessation strategies in patients eligible for lower limb bypass surgery are of utmost importance.

Blood Vessel Prosthesis Implantation↗