Beta-blocker use is associated with lower stroke and death after carotid artery stenting

Abstract

Background Proper selection of patients for carotid artery stenting (CAS) remains controversial despite multiple controlled trials. This relates in part to differences in interpretation of the relative importance of myocardial vs stroke complications after the procedure by different specialties and a lack of granular clinical data to analyze outcomes outside the large clinical trials. The objective of this study was to assess the effect of preoperative medications, procedure parameters, and patient characteristics on outcomes of CAS performed in a multispecialty national database. Methods We analyzed all patients who underwent CAS between 2005 and2014in the Vascular Quality Initiative. A multivariate logistic regression model was built to assess the effects of age, gender, comorbidities, smoking, preprocedure medications, procedure details, and hypotension or hypertension that required intravenous medication on 30-day death or stroke rates. Results A total of 5263patients underwent CAS (mean age, 70years;63%male). The 30-day stroke/death rate was 3.4%(1.5% minor stroke, 0.9% major stroke, and 1.2% death; 40% of patients who had major strokes died within 30 days), and the myocardial infarction rate was 0.8%. Postprocedural hypertension requiring treatment occurred in 519 cases (9.9%), and it was associated with a 3.4-fold increase in stroke/death (odds ratio, 3.39; 95% confidence interval, 2.30–5.00; P < .0001). Preprocedural beta-blocker use for >30 days was associated with a 34% reduction in the stroke/death risk (odds ratio, 0.66; 95% confidence interval, 0.46–0.95; P = .025) compared with nonuse. Beta-blocker use was not associated with postprocedural hypotension. Other predictors of postoperative stroke and death included age, symptomatic status, diabetes (type 1 or type 2), and postprocedural hypotension, whereas prior carotid endarterectomy and distal embolic protection use were protective. Conclusions Postprocedural hypertension and hypotension that require treatment are both strongly associated with periprocedural stroke/death after CAS. Beta blockers significantly reduce the stroke/death risk associated with carotid stenting and should be investigated prospectively for potential use during CAS.

Long-Term Outcomes of Carotid Endarterectomy and Carotid Artery Stenting When Performed by a Single Vascular Surgeon

“…We insure that all our patients are on statin and aspirin as well as β-blockers and for CAS dual antiplatelet agents is mandatory. 15,16 Statins have been shown to be protective for mortality following CEA and CAS in previous studies; similarly in this study, statins have shown 71% reduction in mortality. 16,17 We patch all our CEA under EEG and evoked potential monitoring with selective shunting.…”

Effects of beta-blocker therapy on mortality after elective colon cancer surgery: a Swedish nationwide cohort study

“…Obeid and colleagues found no link between beta-blocker therapy and stroke risk in patients preprocedurally treated with beta-blockers for more than 30 days. 38 This might be explained by the beta-blocker dose administered: in the POISE study patients received 200 mg extended-release metoprolol daily, 34 whereas the highest daily dose prescribed for patients in the current study was 125 mg metoprolol with the majority receiving a dose of 50 mg. Additionally, an overwhelming majority of beta-blocker exposed patients in the current study had received the drug for at least 12 months prior to surgery. This contrasts with the POISE trial where beta-blocker treated patients were drug-naïve up until drug-initiation immediately before surgery, suggesting that a period of Open access adjustment to the drug may be beneficial prior to the patient undergoing surgery.…”

Stenting versus endarterectomy after prior ipsilateral carotid endarterectomy

“…The negative effect of smoking gives credence to the need for vascular surgeons and interventionists to contribute actively to multidisciplinary efforts to help patients quit smoking. The avoidance of ballooning after stent deployment 29,30 and the use of b-blockers 31 have been shown to positively affect CAS outcomes in patients with de novo disease. These might also be useful in further improving outcomes after treatment of restenosis with CAS.…”