Background:The 1996 atenolol study provided evidence that perioperative -adrenergic receptor blockade (-blockade) reduced postsurgical mortality. In 1998, the indications for perioperative -blockade were codified as the Perioperative Cardiac Risk Reduction protocol and implemented at the San Francisco Veterans Administration Medical Center, San Francisco, California. The present study analyzed the association of the pattern of use of perioperative -blockade with perioperative mortality since introduction of the Perioperative Cardiac Risk Reduction protocol. Methods: Epidemiologic analysis of the operations undertaken since 1996 at the San Francisco Veterans Administration Medical Center was performed. The pattern of use of perioperative -blockade was divided into four groups: None, Addition, Withdrawal, and Continuous. Logistic regression, survival analysis, and propensity analysis were performed. Results: A total of 38,779 operations were performed between 1996 and 2008. In patients meeting Perioperative Cardiac Risk Reduction indications for perioperative -blockade, Addition is associated with a reduction in 30-day (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.33 to 0.83; P ϭ 0.006) and 1-yr mortality (OR, 0.64; 95%, CI 0.51 to 0.79; P Ͻ 0.0001). Continuous is associated with a reduction in 30-day (OR, 0.68; 95% CI, 0.47 to 0.98; P ϭ 0.04) and 1-yr mortality (OR, 0.82; 95% CI, 0.67 to 1.0; P ϭ 0.05). Withdrawal is associated with an increase in 30-day (OR 3.93, 95% CI, 2.57 to 6.01; P less than 0.0001) and 1-yr mortality (OR, 1.96; 95% CI, 1.49 to 2.58; P Ͻ 0.0001). Conclusion: Perioperative -blockade administered according to the Perioperative Cardiac Risk Reduction protocol is associated with a reduction in 30-day and 1-yr mortality. Perioperative withdrawal of -blockers is associated with increased mortality.
BACKGROUND
Angiotensin‐converting enzyme inhibitors (ACE‐Is) are a widely used class of cardiovascular medication. However, limited data exist on the risks of postoperative nonresumption of an ACE‐I.
OBJECTIVE
To evaluate the factors and 30‐day mortality risks associated with the postoperative nonresumption of an ACE‐I.
DESIGN
A retrospective cohort study.
SETTING
Veterans Affairs (VA) Healthcare System.
PATIENTS
A total of 294,505 admissions in 240,978 patients with multiple preoperative prescription refills (>3) for an ACE‐I who underwent inpatient surgery from calendar years 1999 to 2012.
INTERVENTION
None.
MEASUREMENTS
We classified surgical admissions based upon the timing of postoperative resumption of an ACE‐I prescription from the day of surgery through postoperative days 0 to 14 and 15 to 30, and collected 30‐day mortality data. We evaluated the relationship between 30‐day mortality and the nonresumption of an ACE‐I from postoperative day 0 to 14 using proportional hazard regression models, adjusting for patient‐ and hospital‐level risk factors. Sensitivity analyses were conducted using more homogeneous subpopulations and propensity score models.
RESULTS
Twenty‐five percent of our cohort did not resume an ACE‐I during the 14 days following surgery. Nonresumption of an ACE‐I within postoperative day 0 to 14 was independently associated with increased 30‐day mortality (hazard ratio: 3.44; 95% confidence interval: 3.30‐3.60; P < 0.001) compared to the restart group. Sensitivity analyses maintained this relationship.
CONCLUSIONS
Nonresumption of an ACE‐I is common after major inpatient surgery in the large VA Health Care System. Restarting of an ACE‐I within postoperative day 0 to 14 is, however, associated with decreased 30‐day mortality. Careful attention to the issue of timely reinstitution of chronic medications such as an ACE‐I is indicated. Journal of Hospital Medicine 2014;9:289–296. 2014 Society of Hospital Medicine
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.