A reply

Thank you to Drs Powell and Maharaj for their interest in our article. We agree with Dr Powell that patients should not present for vascular surgery without appropriate pre-operative preparation. However, although it is suggested that all patients presenting for vascular surgery should be considered for statin therapy [1], only half of elective abdominal aortic aneurysm (AAA) surgery patients receive statins [2]. The cardiac outcome of major vascular surgical patients may therefore be adversely affected by inadequate medical therapy. Thus, anaesthetists may have to contribute to the medical management of these high-risk patients. In order to make reasonable risk-benefit decisions regarding timing of surgery, anaesthetists need to understand the mechanisms and duration of time necessary to achieve cardioprotection following initiation of medical therapy. In addition, scrutiny of peri-operative data regarding medical therapy is important. For example, although beta-blockers are widely indicated for cardiovascular medical conditions [3], cardioprotection during surgery is less convincing, with possible protection following acute administration [4], and an absence of cardioprotection in chronically beta-blocked patients [5]. One would not expect this if only the non-surgical literature was analysed. An awareness of the cardioprotective implications of acute withdrawal of certain drugs in the peri-operative period is necessary [6]. Dr Maharaj suggests that peri-operative statin recommendations could wait until the publication of the DECREASE-IV trial [7], which will be the first trial including all types of major non-cardiac surgery. The currently published prospective studies of peri-operative statin therapy [8, 9] report on high-risk vascular patients with a control group mortality of 4%[10]. The 30-day mortality following elective open AAA procedures in the NCEPOD report was 6.2%[2]. Half of these deaths were cardiac. With a number-needed-to-treat of 23 to prevent a peri-operative myocardial infarction with statin therapy [10], denying these patients statins until 2008 is unacceptable. Where the DECREASE-IV trial will add substantial value is in the recruitment of patients of lower cardiovascular risk, undergoing non-vascular non-cardiac surgery. Finally, we agree that the model proposed by Kertai et al. [11] may be more appropriate than that of Lee et al. [12] when considering vascular surgical patients.