Angiotensin-converting Enzyme Inhibitors are Superior to Beta Blockers in Preventing Mortality and Aneurysmal Rupture Following Open and Endovascular Aneurysm Repair

Optimal blood pressure control following endovascular (EVAR) or open abdominal aneurysm repair (OAR) is crucial in reducing post repair complications. In hospital continuation of preoperative beta blocker (BB) has shown a significant reduction in postoperative mortality following repair. Although treatment with angiotensin converting enzyme inhibitors (ACEIs) is associated with a reduction in mortality among patients with abdominal aortic aneurysms (AAAs) regardless of repair status. Nevertheless, the best medical therapy to control hypertension following AAA repair is yet to be determined. We examined whether treatment with ACEI vs BB influenced postoperative and 1-year outcomes following AAA repair in a Medicare-linked database. All hypertensive patients undergoing EVAR and OAR in the VQI-VISION between 2003 and 2018 were included. Patients were divided into two groups based on their preoperative and discharge medications either ACEI or BB. Postoperative outcomes included mortality, renal complications, leg ischemia, respiratory complications, pneumonia, and non-home discharge. One-year outcomes included all-cause mortality, aneurysmal rupture, and reintervention. Multivariable logistic regression analysis was used to assess postoperative outcomes, and Kaplan-Meier survival and Cox proportional hazard regression analyses were used to evaluate 1-year outcomes. Our cohort included 8789 patients; of these, 3523 patients (40.1%) were on ACEI and 5,266 (59.9%) were on BB. Patients on ACEI were more likely to be males (79.8% vs 77.4%; P = .010), Hispanic (3.5% vs 2.1%; P < .001), current smokers (29.7% vs 26.5%; P = .007), and diabetics (24% vs 19.4%; P < .001). Patients on BB had higher rates of congestive heart failure (17.3% vs 6.2%; P < .001), chronic kidney disease (43.1% vs 35.5%; P < .001), coronary artery disease (51.5% vs 25.3%; P < .001), and chronic obstructive pulmonary disease (37.4% vs 32%; P < .001). ACEI use was associated with lower risk of postoperative mortality (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-0.8; P = .014), leg ischemia (OR, 0.5; 95% CI, 0.3-0.98; P = .043), myocardial infarction (OR, 0.1; 95% CI, 0.03-0.5; P = .004), respiratory complications (OR, 0.5; 95% CI, 0.3-0.8; P < .001), pneumonia (OR, 0.4; 95% CI, 0.2-0.8; P = .012), renal complications (OR, 0.5; 95% CI, 0.3-0.7; P < .001), and non-home discharge (OR, 0.47; 95% CI, 0.4-0.6; P < .001). At 1 year, ACEI use was associated with lower mortality (hazard ratio, 0.5; 95% CI, 0.4-0.7; P < .001) and lower risk of aneurysmal rupture (hazard ratio, 0.7; 95% CI, 0.5-0.9; P = .017) (Figures 1, 2). In this large contemporary retrospective cohort study, ACEI use was associated with favorable postoperative outcomes compared with BB use. It was also associated with lower mortality and aneurysmal rupture at 1 year of follow-up. These findings suggest that ACEIs may be involved in vascular inflammation reduction of several vascular beds in addition to hypertension control.Fig 2Freedom from rupture.View Large Image Figure ViewerDownload Hi-res image Download (PPT)