Perioperative management with antiplatelet and statin medication is associated with reduced mortality following vascular surgery

Abstract

Objective Many patients undergoing vascular surgical procedures are not on appropriate medical therapy. This study sought to examine the variation and impact of antiplatelet (AP) and statin therapy on early and late mortality in patients undergoing vascular surgery in our region. Methods We studied all patients (n = 14,489) undergoing elective carotid endarterectomy (n = 6978), carotid stenting (n = 524), and suprainguinal (n = 763) and infrainguinal bypass (n = 3053), as well as patients with known coronary risk factors undergoing open (n = 1044) and endovascular (n = 2127) abdominal aortic aneurysm repair from 2005 to 2012 in the Vascular Study Group of New England. Optimal medical management was defined as treatment with both AP and statin agents, preoperatively and at discharge. We analyzed temporal, procedural, and center variation of medication use. Multivariable analyses were used to determine the adjusted impact of AP and statin therapy on 30-day mortality and 5-year survival. Results Optimal medical management improved over the study interval (55% in 2005 to 68% in 2012; P trend < .01) with carotid interventions having the highest rates of optimal medications use (carotid artery stenting, 78%; carotid endarterectomy, 74%) and abdominal aortic aneurysm repair in patients with known cardiac risk factors having the lowest (open, 57%; endovascular aneurysm repair, 56%). Optimal medication use varied by center as well (range, 40%-86%). Preoperative AP and statin use was associated with reduced 30-day mortality (odds ratio, 0.76; 95% confidence interval [CI], 0.5-1.05; P = .09). AP and statin prescription at discharge was additive in survival benefit with improved 5-year survival (hazard ratio, 0.5; 95% CI, 0.4-0.7; P< .01) that was consistent across procedure types. Patients prescribed AP and statin at discharge had 5-year survival of 79% (95% CI, 77%-81%) compared with only 61% (95% CI, 52%-68%; P< .001) for patients on neither medication. Conclusions AP and statin therapy preoperatively and at discharge was associated with reduced 30-day mortality and an absolute 18% improved 5-year survival after vascular surgery. However, one-third of patients are suboptimally managed in real world practice. This demonstrates an opportunity for quality improvement that can substantially improve survival after vascular surgery.

Quality of care among patients undergoing lower extremity revascularization

“…23 In our cohort, patient outcome did not appear altered by use of appropriate, guideline-based medical therapy. Our findings are in contrast to other studies that have shown a decrease in mortality, 24 major adverse cardiac and cerebral events, 19 and major adverse limb events 15,19,25 with guideline-based medical therapy. Patients in the Vascular Study Group of New England cohort who were treated with an antiplatelet and statin demonstrated improved 30-day and five-year survival compared with patients not receiving these agents.…”

“…Patients in the Vascular Study Group of New England cohort who were treated with an antiplatelet and statin demonstrated improved 30-day and five-year survival compared with patients not receiving these agents. 24 Only 26% of patients in that series underwent arterial bypass (the remainder underwent carotid intervention or repair of abdominal aortic aneurysm), and the degree of LE ischemia was not reported. Ardati and colleagues found that users of aspirin and statins had decreased peripheral intervention, limb salvage surgery, and amputation at six months, but no difference in death, myocardial infarction, and stroke.…”

Rupture rates of untreated large abdominal aortic aneurysms in patients unfit for elective repair

“…There is greater awareness and use of best medical therapy, including antiplatelet, statin, and risk factor modification therapy. 10,11 A shift has occurred toward the use of endovascular repair, which has a very low postoperative mortality and may even be performed percutaneously under local anesthetic. 26 A combination of these factors may explain the trends observed over time.…”

“…9 Medical management including statins, antiplatelet agents, and antihypertensives 10,11 are all now commonly used in patients with AAA and are thought to reduce rupture risk. A contemporary rupture rate for patients unfit for intervention at 5.5 cm is important for surgeons to accurately reconsider intervention at a larger size, if at all.…”

Preoperative Rosuvastatin Protects Patients with Coronary Artery Disease Undergoing Noncardiac Surgery

“…Previous studies on the protective effect of statins against perioperative myocardial necrosis focused mainly on vascular surgery [9,22] and CABG [10], not on general surgery. In a recent retrospective cohort study, Raju et al [23] found that statin use in the perioperative period was associated with a reduction in adverse cardiovascular events and 30-day all-cause mortality.…”