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Pre-operative Beta Blockade is associated with Increased Rates of 30-day MACE in Patients undergoing Infrainguinal Revascularization for Critical Limb Ischemia
Alexander H. Shannon, MD, J Hunter Mehaffey, MD, J Michael Cullen, MD, Irving L. Kron, MD, Gilbert R. Upchurch, Jr., MD, William P. Robinson, MD.
University of Virginia, Charlottesville, VA, USA.

Approximately 55% of patients with peripheral arterial disease have coronary artery disease and are accordingly treated with beta-blockers. However, the effects of preoperative beta-blocker utilization on outcomes after revascularization for critical limb ischemia (CLI) are unclear. The objective of this study was to assess the impact of pre-operative beta-blockade on 30-day Major Adverse Cardiac Events (MACE) and Major Adverse Limb Events (MALE) in patients undergoing infrainguinal revascularization for CLI. We hypothesize that rates of MALE and MACE will be higher in patients not on pre-operative beta-blockade
The National Surgical Quality Improvement Program (NSQIP) Vascular Targeted File 2011-2014 identified patients undergoing infrainguinal endovascular intervention and bypass for CLI as well as beta-blocker utilization. Primary outcomes were 30-day MACE (Stroke, Myocardial Infarction (MI), or death) and MALE (Untreated Loss of Patency, Re-intervention, or Amputation). Multivariate logistic regression was utilized to identify independent predictors of MACE and MALE.
A total of 11,785 revascularizations were performed for CLI (preoperative beta-blocker: 7,365, no preoperative beta-blocker: 4,420). There were 7,408 bypasses (preoperative beta-blocker: 4,541(61.7%), no preoperative beta-blocker: 2,867(64.9%), p<0.01) and 4,377 endovascular procedures (preoperative beta-blocker: 2,824(38.3%), no preoperative beta-blocker: 1,553(35.1%), p<0.01). MACE was higher in preoperative beta-blocker group compared to no preoperative beta-blocker group (424(5.8%), 152(3.4%), respectively, p<0.0001), as was myocardial infarction (MI) (pre-operative beta-blocker: 225(3.1%), no preoperative beta-blocker 78(1.8%), p<0.0001) and 30-day mortality (pre-operative beta-blocker: 197(2.7%), no pre-operative beta-blocker: 75(1.7%), p=0.0006). MALE was similar between preoperative beta-blocker and no preoperative beta-blocker (765(10.4%) vs 473(10.7%), respectively, p=0.59). After controlling for cardiac risk factors, beta-blockade independently predicted MACE (OR 1.27, p=0.03) and MI (OR 1.36, p=0.03), but not stroke (1.17, p=0.58) or 30-day mortality (OR 1.22, p=0.19). Beta-blocker utilization did not predict MALE (OR 0.99, p=0.87)
In patients with CLI, preoperative beta-blocker utilization was an independent predictor of 30-day MI and MACE after controlling for other cardiovascular risk factors. The safety of beta blocker utilization in patients with CLI deserves further investigation.

Table 1. 30-day MALE and MACE outcomes among the treatment groups
ParameterPre-operative Beta-Blocker
No Pre-operative Beta-Blocker
MALE765 (10.4%)473 (10.7%)0.59
Untreated Loss of Patency168 (2.3%)111 (2.5%)0.43
Re-intervention391 (5.3%)243 (5.5%)0.66
Amputation372 (5.1%)224 (5.1%)0.97
MACE424 (5.8%)152 (3.4%)<0.0001
CVA51 (0.69%)20 (0.45%)0.103
MI225 (3.1%)78 (1.8%)<0.0001
Mortality197 (2.7%)75 (1.7%)0.0006

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