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Protecting the Heart with Cardiac Medication in Patients with Left Ventricular Dysfunction Undergoing Major Noncardiac Vascular Surgery

Department of Anesthesiology, Erasmus MC, Rotterdam

Jeroen J. Bax, MD, PhD

Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands

O. Schouten, MD

Department of Vascular Surgery, Erasmus MC, Rotterdam

D. Poldermans, MD, PhD

Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, Room H-921, 3015 GD Rotterdam, The Netherlands; d.poldermans{at}erasmusmc.nl

Patients with left ventricular dysfunction who are undergoing major noncardiac vascular surgery are at increased risk of adverse postoperative events. We sought to evaluate whether perioperative medication use, including angiotensin-converting enzyme (ACE) inhibitors,b-blockers, statins, and aspirin, was associated with a reduced incidence of postoperative in-hospital mortality in these high-risk patients. The study enrolled 511 patients with left ventricular dysfunction (left ventricular ejection fraction <30%) who were undergoing major noncardiac vascular surgery. Cardiac risk factors and medication use were noted before surgery. Preoperative dobutamine stress echocardiography (DSE) was performed to identify patients with stress-induced myocardial ischemia. The end point was postoperative in-hospital mortality. Univariate and multivariate logistic regression analyses were performed to evaluate the relation between perioperative medication use and mortality. The mean age of the study population was 64 ± 11 years, and 75% were men. Perioperative use of ACE inhibitors, b-blockers, statins, and aspirin was recorded in 215 (48%), 139 (27%), 107 (21%), and 125 patients (24%), respectively. Stress-induced myocardial ischemia occurred in 82 patients (16%). Sixty-four patients (13%) died. Perioperative use of ACE inhibitors (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.12-0.91), b-blockers (OR, 0.03; 95% CI, 0.01-0.26), statins (OR, 0.06; 95% CI, 0.01-0.53), and aspirin (OR, 0.13; 95% CI, 0.03-0.55), was significantly associated with a reduced incidence of mortality, after adjusting for cardiac risk factors and DSE results. In conclusion, the present study showed that the perioperative use of ACE inhibitors,b-blockers, statins, and aspirin is independently associated with a reduced incidence of in-hospital mortality in patients with left ventricular dysfunction who are undergoing major noncardiac vascular surgery.

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