Preoperative β-blockers do not improve cardiac outcomes after major elective vascular surgery and may be harmful.
Preoperative β-blockers do not improve cardiac outcomes after major elective vascular surgery and may be harmful.
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DOI：
10.1016/j.jvs.2015.01.053
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发表时间：
2015-07
影响因子：
4.3
通讯作者：
Beck A
中科院分区：
文献类型：
--
作者：
Scali S;Patel V;Neal D;Bertges D;Ho K;Jorgensen JE;Cronenwett J;Beck A
由于数据相互矛盾，血管手术前常规开始β受体阻滞剂治疗存在争议。本分析的目的是确定在择期大血管手术前预防性使用β受体阻滞剂是否能降低术后心脏事件或死亡率。使用血管外科学会血管质量倡议（SVS-VQI）数据集对腹股沟下下肢旁路（LEB）、腹股动脉旁路（AFB）和开放性腹主动脉瘤（AAA）修复术患者进行回顾性队列分析。排除慢性（术前> 30天）β受体阻滞剂患者，并比较术前（0 - 30天）和无β受体阻滞剂组。使用专门来自SVS-VQI数据集的新型预测工具对患者进行风险分层。进行倾向匹配配对和手术间特定风险分层比较。终点包括院内主要不良心脏事件（MACE），包括心肌梗死（MI;定义为新的ST或T波心电图变化、肌钙蛋白升高或超声心动图或其他成像方式记录）、心律失常和充血性心力衰竭，以及30天死亡率。该研究分析了13，291例患者（LEB，68%[n = 9047]; AFB，11%[n = 1474];开放性AAA，21%[n = 2770]）;其中，67.7%（n = 8999）在首次手术时接受β受体阻滞剂。具体而言，确定13.2%（n = 1753）开始接受术前β受体阻滞剂治疗，54.5%（n = 7426）接受长期β受体阻滞剂治疗，32.3%（n = 4286）未接受术前β受体阻滞剂治疗。在这三种手术中，患者具有显著的人口统计学和合并症差异，因此未合并。一项1：1倾向匹配配对分析（1459对）显示，术前使用β受体阻滞剂的患者术后MI发生率较高（术前β受体阻滞剂相对风险为1.65; 95%置信区间为1.02 - 2.68; P = 0.05 vs无β受体阻滞剂），但在心律失常、充血性心力衰竭或30天死亡率方面无差异。当在每种手术中分层为低风险、中等风险和高风险组时，所有术前β受体阻滞剂组患者的MACE和30天死亡率没有差异或更高，但高风险开放性AAA患者除外，其MI发生率较低（比值比，0.35; 95%置信区间，0.11 - 0.87; P = 0.04）。排除高危开放性AAA患者，术前β受体阻滞剂未降低LEB、AFB或开放性AAA后的MACE率或死亡率。重要的是，在几个亚组中，预防性术前β受体阻滞剂暴露增加了某些不良事件的发生率。鉴于这些数据，SVS-VQI不能支持大多数患者在重大择期血管手术前常规启动术前β受体阻滞剂。
Routine initiation β-blocker medications before vascular surgery is controversial due to conflicting data. The purpose of this analysis was to determine whether prophylactic use of β-blockers before major elective vascular surgery decreased postoperative cardiac events or mortality. The Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI) data set was used to perform a retrospective cohort analysis of infrainguinal lower extremity bypass (LEB), aortofemoral bypass (AFB), and open abdominal aortic aneurysm(AAA) repair patients. Chronic (>30 days preoperatively) β-blocker patients were excluded, and comparisons were made between preoperative (0–30 day) and no β-blocker groups. Patients were risk stratified using a novel prediction tool derived specifically from the SVS-VQI data set. Propensity-matched pairs and interprocedural specific risk stratification comparisons were performed. End points included in-hospital major adverse cardiac events (MACEs), including myocardial infarction (MI; defined as new ST or T wave electrocardiographic changes, troponin elevation, or documentation by echocardiogram or other imaging modality), dysrhythmia, and congestive heart failure, and 30-day mortality. The study analyzed 13,291 patients (LEB, 68% [n = 9047]; AFB, 11% [n = 1474]; and open AAA, 21% [n = 2770]); of these, 67.7% (n = 8999) were receiving β-blockers at time of their index procedure. Specifically, 13.2% (n = 1753) were identified to have been started on a preoperative β-blocker, 54.5% (n=7426) were on chronic β-blockers, and 32.3% (n=4286) were on no preoperative β-blockers. Among the three procedures, patients had significant demographic and comorbidity differences and thus were not combined. A 1:1 propensity-matched pairs analysis (1459 pairs) revealed higher rates of postoperative MI with preoperative β-blockers (preoperative β-blocker relative risk, 1.65; 95% confidence interval, 1.02–2.68; P = .05 vs no β-blocker), with no difference in dysrhythmia, congestive heart failure, or 30-day mortality. When stratified into low-risk, medium-risk, and high-risk groups within each procedure, all groups of preoperative β-blocker patients had no difference or higher rates of MACEs and 30-day mortality, with the exception of high-risk open AAA patients, who had a lower rate of MI (odds ratio, 0.35; 95% confidence interval, 011–0.87; P = .04). Exclusive of high-risk open AAA patients, preoperative β-blockers did not decrease rates of MACEs or mortality after LEB, AFB, or open AAA. Importantly, exposure to prophylactic preoperative β-blockers increased the rates of some adverse events in several subgroups. Given these data, the SVS-VQI cannot support routine initiation of preoperative β-blockers before major elective vascular surgery in most patients.
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DOI：
10.1136/heartjnl-2013-304262
发表时间：
2014-03
期刊：
Heart (British Cardiac Society)
影响因子：
--
作者：
Bouri S;Shun-Shin MJ;Cole GD;Mayet J;Francis DP
通讯作者：
Francis DP
DOI：
10.1016/s0735-1097(01)01788-0
发表时间：
2002-02-06
影响因子：
24
作者：
Eagle, KA;Berger, PB;Smith, SC
通讯作者：
Smith, SC
影响因子：
4.3
作者：
Goodney, Philip P.;Eldrup-Jorgensen, Jens;Cronenwett, Jack L.
通讯作者：
Cronenwett, Jack L.
影响因子：
120.7
作者：
London, Martin J.;Hur, Kwan;Henderson, William G.
通讯作者：
Henderson, William G.
影响因子：
168.9
作者：
Devereaux, P. J.;Yang, Homer;Choi, Peter
通讯作者：
Choi, Peter