COVID-19

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Development of Persistent Opioid Use After Cardiac Surgery

Brown CR, Chen Z, Khurshan F, Groeneveld PW, Desai ND. JAMA Cardiol. doi:10.1001/jamacardio.2020.1445 Published online June 17, 2020.

 

Key Points:

  • Background: Opioids prescribing for pain management have contributed to long term issues related to opioid use.
  • Objective: To assess the frequency and discharge dose factors following cardiac surgery of persistent opioid use in prior opioid nonusers (No opioid RX within 180 days of Cardiac Surgery).
  • Methods:
  • Retrospective cohort study using a national administrative claims data base 1/1/2004 to 12/31/2016
  • Results: (90-180 days post-surgery)
    • Eligible Heart Surgery Patients – 35,817
    • Coronary Bypass Surgery (CABG) – 25,673 (71.7%)
    • Valve Surgery – 10,144 (28.3%)
  • Post Heart Surgery opioid users:
    • CABG – 2609 (10.2).
    • Valve surgery – 821 (8.1%).  (CABG vs. Valve surgery, P<0.001)
  • Risk factors for persistent opioid use:
    • Demographics – CABG surgery, Women, Younger patients
    • Pre-surgery Factors – CHF, Chronic Lung disease, Diabetes, Kidney Failure, Chronic Pain, and Alcoholism, pre op use of benzodiazepines and muscle relaxers.
    • Opioid Dosing: Discharge Rx > 300 mg Oral Morphine Equivalents
    • Limitations:
  • The database is private insure of managed Medicare and may not be representative of all populations.
  • Such databases are subject to coding errors and do not represent other sources of narcotics
  • Conclusions:
    • Approximately 1 in 10 patients post cardiac surgery continue to use opioids > 90 days post-surgery.
    • Higher opioid discharge doses were associated with greater late use.
  • Editorial Comment:
    • Screening patient’s pre-op for opioid risk is important and in patients with both percutaneous as well as surgical revascularization options, opioid use risk may be a useful not usually discussed factor in decision-making.

George W. Vetrovec, MD, MACC, MSCAI

Editorial consultant.

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Effect of Colchicine vs Standard Care on Cardiac and Inflammatory Biomarkers and Clinical Outcomes in Patients Hospitalized With Coronavirus Disease 2019 The GRECCO-19 Randomized Clinical Trial

Deftereos SG, Giannopoulos G, MD, Vrachatis DA, et. al. on behalf of the GRECCO-19 investigators. JAMA Network Open. 2020;3(6):e2013136. doi:10.1001/jamanetworkopen.2020.13136

Key Points:

GRECCO-19 (Greek Study in the Effects of Colchicine in COVID-19 Complications Prevention) is a randomized study involving 16 tertiary care centers in Greece who randomized 105 patients to standard medical care vs. colchicine treatment in the setting of COVID – 19 care.

  • Study Goal: To assess the potential benefit of colchicine treatment to reduce cardiac inflammatory biomarkers and clinical outcomes in hospitalized patients with COVID – 19.
  • Colchicine Dosing: Loading – colchicine 1.5 mg followed by 0.5 mg at 1 hour. Maintenance dose – 0.5 mg twice daily. Dose duration: Up to 3 weeks.
  • Population: Patients – 105; Male – 60 (58.1%); Median Age – 64 (range 54-76); Control Patients – 50 (47.6%), Colchicine Group – 55 (52.4%). [All median ranges expressed as interquartile ranges]
  • Biomarker Results:
    • Median maximum high-sensitivity troponin levels: Control patients – 0.0112 (0.0043-0.0193); Colchicine Group – 0.008 (0.004-0.0135) P=0.34 [Values expressed as ng/ml]
    • Median maximum C-reactive protein levels: Control patients – 4.5 (1.4-8.9);
    • Colchicine Group – 3.1 (0.8-9.8) P=0.73 [Values expressed as mg/dl].
  • Clinical Results:
    • Time to deterioration by 2 points on a 7-grade clinical status scale, ranging from able to resume normal activities to death: Control Group – 7/50 (14%); Colchicine Group – 1/55 (1.8%) [Odds ratio 0.11; 95% CI, 0.01-0.96; P=0.02]
    • Mean (SD) event Free Survival: Control Group – 18.6 days (0.83) days; Colchicine Group – 20.7 (0.31) [log rank P=0.03]
    • D-dimer (Not a prespecified study value): Control Group – 0.92 (0.68 – 2.77); Colchicine Group – (0.76 (0.41 – 1.59) μg/mL [P = .04].
  • Adverse Events: There were no significant differences between groups except for more frequent diarrhea in the Colchicine Group
  • Limitations: No control of other medications or management with patients enrolled in variable additional drug therapy trials including azithromycin and hydroxychloroquine as well as other drugs. Likewise, there were variations in anticoagulation strategies.
  • Conclusions:
    • Colchicine provided a clinical benefit in a small patient population without a prospective biomarker benefit; However, a retrospective evaluation showed significantly lower levels D-dimer levels for colchicine patients suggesting a potential anti-inflammatory effect on an recognized COVID – 19, high risk biomarker.
    • These results should be considered hypothesis generating.

 

 

 

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