Long-term beta blocker use lowers postoperative mortality while initiating beta blockers preoperatively does not improve outcomes in thoracic endovascular aortic repair.
Academic Article
Overview
abstract
OBJECTIVE: Beta-blockers play a pivotal role in reducing perioperative cardiac complications; however, their impact on outcomes following thoracic endovascular aortic repair (TEVAR) remains unknown. Utilizing the Vascular Quality Initiative database, our study aims to uncover the impact and determine the optimal timeframe for initiating beta-blocker therapy prior to TEVAR. METHODS: A total of 4724 TEVAR patients (2016-2023) were grouped as follows: non-beta-blocker users (NBB), beta-blocker initiators ≤30 days prior to procedure (I30), and long-term beta-blocker users for >30 days prior to procedure (L30). Primary outcomes were in-hospital death, stroke, myocardial infarction, and spinal cord ischemia. Secondary outcomes included pulmonary complications, cardiac complications, bowel ischemia, leg ischemia, and prolonged length of stay (≥2 days). A subanalysis was conducted to assess the influence of beta-blocker use by TEVAR indication: type B aortic dissection and thoracic aortic aneurysm. Multivariable logistic regression analysis was performed to control for confounding variables. RESULTS: We identified 1480 NBB (31%), 778 I30 (16%), and 2466 L30 (52%) patients. After adjusting for confounders, I30 patients showed no significant postoperative complication reduction compared with NBB patients. In contrast, L30 patients had reduced odds of perioperative death (adjusted odds ratio [aOR],0.62; 95% confidence interval [CI], 0.40-0.94; P = .025), pulmonary complications (aOR, 0.60; 95% CI, 0.43-0.82; P = .002), and bowel ischemia (aOR, 0.30; 95% CI, 0.12-0.73; P = .009), but had higher rates of spinal cord ischemia (aOR, 1.99; 95% CI, 1.19-3.49; P = .038), compared with NBB patients. When stratified by indication, L30 patients with type B aortic dissection were associated with decreased risks of death (aOR, 0.42; 95% CI, 0.18-0.97; P = .041), stroke (aOR, 0.29; 95% CI, 0.09-0.92; P = .039), and pulmonary complications (aOR, 0.30; 95% CI, 0.13-0.69; P = .004) compared with NBB patients. Among patients with thoracic aortic aneurysm, L30 was associated with higher odds of spinal cord ischemia (aOR, 3.09; 95% CI, 1.34-8.40; P = .014) compared with NBB but had no impact on stroke or death. CONCLUSIONS: Long-term use of beta-blockers was associated with lower perioperative mortality but higher spinal cord ischemia following TEVAR. Patients with type B aortic dissection had the additional benefit of lower stroke rates without increased spinal cord ischemia. In contrast, initiating beta-blockers preoperatively, independent of pathology, was not associated with improved outcomes. Although further prospective studies are necessary, these results indicate that patients should continue their beta-blocker regimen before undergoing TEVAR, and appropriate management of spinal perfusion pressure should be ensured perioperatively.
