title: Preoperative β-blockers do not improve cardiac outcomes after major elective vascular surgery and may be harmful.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla. Electronic address: salvatore.scali@surgery.ufl.edu.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Scali
authors.affiliation: Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Virendra
authors.initials: V
authors.lastname: Patel
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
authors.forename: Daniel
authors.initials: D
authors.lastname: Neal
authors.affiliation: Division of Vascular Surgery, University of Vermont, Burlington, Vt.
authors.forename: Daniel
authors.initials: D
authors.lastname: Bertges
authors.affiliation: Division of Vascular Surgery, Northwestern University, Chicago, Ill.
authors.forename: Karen
authors.initials: K
authors.lastname: Ho
authors.affiliation: Vascular Center, Maine Medical Center, Portland, Me.
authors.forename: Jens-Eldrup
authors.initials: JE
authors.lastname: Jorgensen
authors.affiliation: Heart and Vascular Center, Darmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Jack
authors.initials: J
authors.lastname: Cronenwett
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
authors.forename: Adam
authors.initials: A
authors.lastname: Beck
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage / Q000009:adverse effects*; D016208:Databases, Factual; D004334:Drug Administration Schedule; D017558:Elective Surgical Procedures; D006331:Heart Diseases / Q000139:chemically induced* / Q000175:diagnosis / Q000401:mortality; D006801:Humans; D016015:Logistic Models; D016017:Odds Ratio; D057216:Propensity Score; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000401:mortality
chemical_list: D000319:Adrenergic beta-Antagonists