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Antihypertensive Medications and Late Outcomes in Aortic Dissection
Quick Takes
- In this high-risk cohort of aortic dissection patients, post-discharge ACEI/ARB and beta-blocker prescriptions were associated with ~20% reduction in all-cause mortality, as compared with other antihypertensive drugs.
- All-cause mortality was 15% lower among patients prescribed ARBs than those prescribed ACEIs.
Study Questions:
Among patients presenting with aortic dissection (AD), how are subsequent antihypertensive prescriptions associated with clinical outcomes including mortality and major adverse cardiac and cerebrovascular events (MACCE)?
Methods:
This retrospective cohort study drew upon the Taiwanese National Health Insurance Research Database. Adult patients hospitalized with first-ever AD between 2001 and 2013 were included. Patients were grouped based on antihypertensive prescription claims data from the first 90 days following discharge: 1) angiotensin-converting enzyme inhibitor (ACEI)/angiotensin-receptor blocker (ARB), 2) beta-blocker, and 3) other antihypertensive drug(s) (control group). Patients prescribed both beta-blockers and ACEIs/ARBs were excluded. The primary outcome was all-cause mortality. Secondary outcomes were death due to aortic aneurysm or AD, later aortic operation, MACCE (acute myocardial infarction, stroke, and cardiovascular death), hospital readmission, and new-onset dialysis.
Results:
Of 14,428 patients who survived admission for AD, 7,450 were excluded (among these were 4,587 patients who received both ACEIs/ARBs and beta-blockers), leaving a cohort of 6,978 eligible patients. In the study cohort, 3,492 received a beta-blocker, 1,729 received an ACEI/ARB, and 1,757 received another antihypertensive drug. After adjustment for multiple propensity scores, there were no significant differences in clinical characteristics among the three groups. Use of beta-blockers steadily increased from 2001-2013 (52%-62.4%, p < 0.001 for trend), as did use of ARBs (18.8%-47.2%, p < 0.001), while use of ACEIs declined (22.4%-5.0%, p < 0.001).
During the follow-up period (ending on December 31, 2103), a total of 2,452 patients (35.1%) died. All-cause mortality was lower in the ACEI/ARB group and beta-blocker group than in the control group (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.71-0.89 for ACEIs/ARBs; HR, 0.82; 95% CI, 0.73-0.91 for beta-blockers). All-cause mortality was lower among patients prescribed ARBs than those prescribed ACEIs (HR, 0.85; 95% CI, 0.76-0.95). Although MACCE did not differ significantly among the three groups, the risk of hospital readmission was significantly lower in the ACEI/ARB group (HR, 0.92; 95% CI, 0.84-0.997) and the beta-blocker group (HR, 0.87; 95% CI, 0.81-0.94) than in the control group.
Conclusions:
In this high-risk cohort of AD patients, post-discharge ACEI/ARB and beta-blocker prescriptions were associated with reduced all-cause mortality and hospital readmission, as compared with other antihypertensive drugs. ARBs were associated with lower all-cause mortality than ACEIs.
Perspective:
These findings support current guideline recommendations to use beta-blockers and ACEIs/ARBs for blood pressure management in patients with thoracic aortic disease. ARBs may provide an advantage over ACEIs because of their influence on the transforming growth factor-beta signaling pathway, which has been implicated in aortic aneurysm development. Notable limitations of this study are lack of data on blood pressure control and the exclusion of patients who were prescribed both beta-blockers and ACEIs/ARBs at study outset, particularly considering that combination drug therapy is needed for adequate management of hypertension in most patients.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine, Hypertension
Keywords: Aneurysm, Dissecting, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Antihypertensive Agents, Aortic Aneurysm, Blood Pressure, Cardiac Surgical Procedures, Geriatrics, Hypertension, Myocardial Infarction, Patient Discharge, Patient Readmission, Prescriptions, Renal Dialysis, Secondary Prevention, Stroke, Vascular Diseases
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