Randall R. De Martino1, Jens Eldrup-Jorgensen2, Brian Nolan1, David H. Stone1, Julie Adams3, Daniel J. Bertges3, Jack L. Cronenwett1, Philip P. Goodney1
1Dartmouth-Hitchcock Medical Center, Lebanon, NH; 2Maine Medical Center, Portland, ME; 3University of Vermont, Burlington, VT.
OBJECTIVES: This study examined 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=14,490) undergoing primary elective CEA/CAS (n=7,503), supra/infrainguinal bypass (n=3,816) and open/endo AAA repair with known coronary risk factors (n=3,171) from 2005-2012 in the Vascular Study Group of New England. We defined "optimal medical management" as treatment with both AP and statin agents, pre-operatively and at discharge. We used multivariable analysis to determine the independent impact of AP and statin therapy on 30-day mortality and 5-year survival, and analyzed center variation in medication use.
RESULTS: Pre-operative AP and statin use was associated with reduced 30-day mortality (0.97 vs. 1.58%, RR 0.61, p<0.01). AP and statin prescription at discharge was additive in survival benefit (Figure 1). Pre-op and discharge AP and statin was associated with improved 5-year survival (HR 0.68, CI 0.62-0.77, p<0.01) and consistent across procedure types. The use of optimal medical management increased during the study interval (55% in 2005 to 68% in 2012, p<0.01). However, the proportion of patients on optimal medical therapy varied significantly among the 29 centers, from 40 to 86%, p<0.01.
CONCLUSIONS: Optimal medical management was associated with reduced short and long term mortality. However, one-third of patients are sub-optimally managed in real world practice. This is an opportunity for quality improvement that can substantially improve survival after vascular surgery.
AUTHOR DISCLOSURES: J. Adams: Nothing to disclose; D. J. Bertges: Nothing to disclose; J. L. Cronenwett: Nothing to disclose; R. R. De Martino: Nothing to disclose; J. Eldrup-Jorgensen: Nothing to disclose; P. P. Goodney: Nothing to disclose; B. Nolan: Nothing to disclose; D. H. Stone: Nothing to disclose.
5-Year Survival Based on Discharge Medication Status