Perioperative Beta-blocker and Statin use in Patients with Coronary Artery Disease Undergoing Orthotopic Liver Transplantation

Abstract

Background: In patients that undergo Orthotopic Liver Transplantation (OLT), the presence of Coronary Artery Disease (CAD) is associated with worse short- and long-term outcomes. With reported 3-year mortality rates up to 50%, recent efforts have focused on ways to reduce perioperative cardiovascular risk in this population. While continuation of Beta-Blocker (BB) and statin therapy has been shown to benefit patients with known CAD undergoing intermediate or high-risk noncardiac surgery, it is unknown whether these therapies benefit patients with CAD undergoing OLT. Methods: We retrospectively identified 45 patients that underwent OLT between 2002 and 2010 with known CAD. Records were reviewed and patterns of BB (uninterrupted therapy, interrupted therapy no therapy, at hospital discharge) and statin (preoperative, at hospital discharge) use were categorized as indicated. Chi-square, Fisher's exact test, and ANOVA were employed to compare patterns of use with Length of Stay (LOS), as well as the incidence of death, Myocardial Infarction (MI), and composite death and Myocardial Infarction (MI) at both 30 days and 12 months post-OLT. Results: Thirty-three patients (73%) were on a BB at admission, and of these 20 (61%) had BB therapy withheld for > 48 hours. Twenty-seven (60%) patients were discharged on a BB. Eight patients out of 45 (18%) were on statin therapy chronically and had the drug continued till the time of OLT. Following transplantation, 1 patient (2%) was discharged on a statin. Overall there were 5 (11%) in-hospital MI in the cohort. Of these, none occurred in patients given continuous BB therapy, while 4 occurred in patients that had BB therapy withdrawn (p = 0.118) and 1 in a patient never administered BB. On univariate analysis, mean LOS differed with respect to BB use and was longer in those that had interrupted (20.3 ± 13.9 days) compared with uninterrupted BB therapy (11.5 ± 7.1; p = 0.020). Composite 1-year mortality and MI was 22% and did not differ with regard to BB or statin prescription at the time of discharge. Conclusions: In patients with CAD undergoing OLT there is a high rate of perioperative BB withdrawal. In addition, few patients are on statin therapy at the time of OLT, and most are not administered a statin postoperatively. BB withdrawal in this population was associated with a non-significant increase in 30-day MI and a significant increase in LOS. This observation, from the largest CAD-OLT cohort yet reported, calls for identifying reasons for BB withdrawal and provides support for increased vigilance with respect to BB provision in this population.