Lau Wei C, Froehlich James B, Jewell Elizabeth S, Montgomery Daniel G, Eng Kristina M, Shields Theresa A, Henke Peter K, Eagle Kim A
Department of Anesthesiology, University of Michigan Cardiovascular Center, Ann Arbor, MI 48109, USA.
Ann Vasc Surg. 2013 May;27(4):537-45. doi: 10.1016/j.avsg.2012.12.001. Epub 2013 Mar 25.
Beta-blockers (BB) and statins (S) independently have been shown to reduce perioperative mortality and myocardial infarction (MI) in patients undergoing vascular surgery. In this study we evaluated the benefits of adding aspirin (A) to BB and S (ABBS), with/without angiotensin-converting enzyme inhibitor (ACE-I) on postoperative outcome in high-risk patients undergoing major vascular surgery.
Analysis of consecutive patients undergoing elective vascular surgery at the University of Michigan Cardiovascular Center was performed. Univariate and multivariate analyses were done using cardiac risk index [Revised Cardiac Risk Index (RCRI), coronary artery disease (CAD), insulin-dependent diabetes mellitus (IDDM), cerebral vascular disease, renal dysfunction, congestive heart failure, and major surgery]; pulmonary disease; and A, BB, S (ABBS)±ACE-I use. Baseline clinical characteristics and medication were adjusted using propensity scores. Endpoints were bleeding, 30-day MI, stroke, and 12-month mortality.
Between 2003 and 2010, 4,149 arterial procedures were performed, 819 of which were risk stratified as RCRI≥3. The incidence of MI was 3-fold lower (2.5% vs. 7.8%, OR 0.31, 95% CI 0.15-0.61, P=0.001) in ABBS±ACE-I (n=513) as compared with non-ABBS±ACE-I (n=306). The 12-month mortality was 8-fold lower in ABBS±ACE-I as compared non-ABBS±ACE-I (5.9% vs. 37.5%, HR 0.13, 95% CI 0.08-0.20, P<0.0001). After adjustment for the propensity to use various therapies, A (HR 0.35, 95% CI 0.24-0.53, P<0.0001), BB (HR 0.65, 95% CI 0.43-1.0, P=0.05), and S (HR 0.36, 95% CI 0.25-0.53, P<0.0001) remained associated with improved 12-month survival. ACE-I use (HR 0.80, 95% CI 0.54-1.19, P=0.27) was not predictive. Aspirin did not predict severe/moderate bleeding.
In high-risk patients undergoing major vascular surgery, ABBS therapy has superior 30-day and 12-month risk reduction benefits for MI, stroke, and mortality as compared with A, BB, or S independently. ACE-I did not demonstrate additional risk-reduction benefits.
β受体阻滞剂（BB）和他汀类药物（S）已被证明可独立降低血管手术患者的围手术期死亡率和心肌梗死（MI）发生率。在本研究中，我们评估了在BB和S（ABBS）基础上加用阿司匹林（A），无论有无血管紧张素转换酶抑制剂（ACE-I），对接受大血管手术的高危患者术后结局的影响。
对密歇根大学心血管中心接受择期血管手术的连续患者进行分析。使用心脏风险指数[修订心脏风险指数（RCRI）、冠状动脉疾病（CAD）、胰岛素依赖型糖尿病（IDDM）、脑血管疾病、肾功能不全、充血性心力衰竭和大手术]、肺部疾病以及A、BB、S（ABBS）±ACE-I的使用情况进行单因素和多因素分析。使用倾向评分对基线临床特征和用药情况进行调整。观察终点为出血、30天内心肌梗死、中风和12个月死亡率。
2003年至2010年期间，共进行了4149例动脉手术，其中819例风险分层为RCRI≥3。与未使用ABBS±ACE-I的患者（n = 306）相比，使用ABBS±ACE-I的患者（n = 513）心肌梗死发生率降低了3倍（2.5%对7.8%，OR 0.31，95% CI 0.15 - 0.61，P = 0.001）。与未使用ABBS±ACE-I的患者相比，使用ABBS±ACE-I的患者12个月死亡率降低了8倍（5.9%对37.5%，HR 0.13，95% CI 0.08 - 0.20，P < 0.0001）。在对使用各种治疗方法的倾向进行调整后，A（HR 0.35，95% CI 0.24 - 0.53，P < 0.0001）、BB（HR 0.65，95% CI 0.43 - 1.0，P = 0.05）和S（HR 0.36，95% CI 0.25 - 0.53，P < 0.0001）仍与12个月生存率的改善相关。使用ACE-I（HR 0.80，95% CI 0.54 - 1.19，P = 0.27）无预测作用。阿司匹林不能预测严重/中度出血。
在接受大血管手术的高危患者中，与单独使用A、BB或S相比，ABBS治疗在降低30天和12个月内心肌梗死、中风和死亡率方面具有更显著的益处。ACE-I未显示出额外的降低风险益处。
