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Does Preoperative Statin, Beta Blocker, and Diuretic Use Influence the Clinical Presentation and Outcome

Benjamin S. Brooke, MD, David C. Chang, PhD, Matthew J. McGirt, MD, Graeme F. Woodworth, MD, Alexander Coon, MD, Glen R. Roseborough, MD, Julie A. Freischlag, MD and Bruce A. Perler, MD
Johns Hopkins Hospital, Baltimore, MD

Objective(s): Patients who present for carotid endarterectomy (CEA) with symptoms of stroke or transient ischemic attack (TIA) have worse postoperative outcomes than patients with asymptomatic carotid disease. We undertook this study to see whether preoperative medication use or patient characteristics influence the presence of symptomatic cerebrovascular disease at the time of surgery.
Methods: A retrospective case-control study was performed among patients presenting for elective CEA at a single academic institution between 1994 and 2004. A total of 660 (42%) symptomatic patients were identified from an institutional database, and compared with 901 (58%) control patients who were asymptomatic at the time of CEA. The independent association of cerebrovascular symptoms with patient variables was assessed using multivariate logistic regression analysis following propensity score adjustment.
Results: The mean age and gender distribution were similar between cases and controls, although symptomatic patients were more likely to have the presence of an ulcerative plaque (18% symptomatic vs. 11% asymptomatic; P<0.001) and unilateral carotid stenosis less than 80 percent (20.6% symptomatic vs. 12.9% asymptomatic; P<0.001). Compared to asymptomatic controls, patients presenting for CEA with symptoms of stroke or TIA were less likely to have hyperlipidemia (43% vs 55%; P<0.001) or a history of coronary artery disease (43% vs 54%; P<0.001), as well as less likely to be receiving statins (35% vs. 47%; P<0.001), beta-blockers (34% vs. 44%; P<0.001), and diuretics (22% vs. 31%; P<0.001). After controlling for potential interaction and confounding using propensity score adjustment and logistic regression analysis, preoperative use of statins (adjusted OR: 0.71 [95%CI: 0.55-0.91]) beta-blockers (adjusted OR: 0.77 [95%CI: 0.61-0.97]) and diuretics (adjusted OR: 0.74 [95%CI: 0.58-0.95]) were all independently associated with a lower likelihood of presenting with cerebrovascular symptoms at the time of CEA.
Conclusions: We observed that patients receiving statins, beta-blockers, or diuretics were less likely to present for CEA with symptoms of stroke or TIA. These data raise the question of whether the preoperative use of these medications protects patients with carotid stenosis from developing symptomatic disease, and contributes to improved outcomes among patients undergoing CEA. Further research is needed to assess the optimal medical management of patients prior to vascular surgery.