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Updated: May 12, 2026
Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Impact of adding aspirin to beta-blocker and statin in high-risk patients undergoing major vascular surgery
Wei C Lau1, James B Froehlich, Elizabeth S Jewell
1Department of Anesthesiology, University of Michigan Cardiovascular Center, Ann Arbor, MI 48109, USA. barbhamm@med.umich.edu
Insights
Adding aspirin, beta-blockers, and statins (ABBS) significantly reduces myocardial infarction (MI) and mortality in high-risk vascular surgery patients. This combination therapy offers superior outcomes compared to individual medications, with no added benefit from ACE inhibitors.
Area of Science:
- Cardiovascular Surgery
- Pharmacology
- Clinical Outcomes Research
Background:
- Beta-blockers (BB) and statins (S) are known to reduce perioperative mortality and myocardial infarction (MI).
- High-risk patients undergoing major vascular surgery require optimized perioperative management.
- The combined benefit of aspirin (A), BB, and S (ABBS) with or without ACE inhibitors (ACE-I) on postoperative outcomes is not fully understood.
Purpose of the Study:
- To evaluate the efficacy of adding aspirin (A) to beta-blockers (BB) and statins (S) therapy (ABBS) in high-risk patients undergoing major vascular surgery.
- To assess the additional benefit of angiotensin-converting enzyme inhibitors (ACE-I) when combined with ABBS.
- To determine the impact of ABBS therapy on 30-day MI, stroke, and 12-month mortality.
Main Methods:
- Analysis of consecutive patients undergoing elective vascular surgery.
- Risk stratification using the Revised Cardiac Risk Index (RCRI).
- Univariate and multivariate analyses, adjusted for baseline characteristics and medication use via propensity scores.
Main Results:
- The ABBS±ACE-I group showed a 3-fold lower incidence of MI (2.5% vs. 7.8%) compared to the non-ABBS±ACE-I group.
- 12-month mortality was 8-fold lower in the ABBS±ACE-I group (5.9% vs. 37.5%).
- Aspirin, beta-blockers, and statins independently predicted improved 12-month survival; ACE-I did not show significant benefit. Aspirin use was not associated with increased bleeding.
Conclusions:
- ABBS therapy provides superior risk reduction for MI, stroke, and mortality in high-risk vascular surgery patients compared to individual agents.
- Adding aspirin to beta-blockers and statins is beneficial for perioperative outcomes in this population.
- Angiotensin-converting enzyme inhibitors do not offer additional risk-reduction benefits when used with ABBS therapy.
Background:
Beta-blockers (BB) and statins (S) independently have been shown to reduce perioperative mortality and myocardial infarction (MI) in patients undergoing vascular surgery. In this study we evaluated the benefits of adding aspirin (A) to BB and S (ABBS), with/without angiotensin-converting enzyme inhibitor (ACE-I) on postoperative outcome in high-risk patients undergoing major vascular surgery.
Methods:
Analysis of consecutive patients undergoing elective vascular surgery at the University of Michigan Cardiovascular Center was performed. Univariate and multivariate analyses were done using cardiac risk index [Revised Cardiac Risk Index (RCRI), coronary artery disease (CAD), insulin-dependent diabetes mellitus (IDDM), cerebral vascular disease, renal dysfunction, congestive heart failure, and major surgery]; pulmonary disease; and A, BB, S (ABBS)±ACE-I use. Baseline clinical characteristics and medication were adjusted using propensity scores. Endpoints were bleeding, 30-day MI, stroke, and 12-month mortality.
Results:
Between 2003 and 2010, 4,149 arterial procedures were performed, 819 of which were risk stratified as RCRI≥3. The incidence of MI was 3-fold lower (2.5% vs. 7.8%, OR 0.31, 95% CI 0.15-0.61, P=0.001) in ABBS±ACE-I (n=513) as compared with non-ABBS±ACE-I (n=306). The 12-month mortality was 8-fold lower in ABBS±ACE-I as compared non-ABBS±ACE-I (5.9% vs. 37.5%, HR 0.13, 95% CI 0.08-0.20, P<0.0001). After adjustment for the propensity to use various therapies, A (HR 0.35, 95% CI 0.24-0.53, P<0.0001), BB (HR 0.65, 95% CI 0.43-1.0, P=0.05), and S (HR 0.36, 95% CI 0.25-0.53, P<0.0001) remained associated with improved 12-month survival. ACE-I use (HR 0.80, 95% CI 0.54-1.19, P=0.27) was not predictive. Aspirin did not predict severe/moderate bleeding.
Conclusions:
In high-risk patients undergoing major vascular surgery, ABBS therapy has superior 30-day and 12-month risk reduction benefits for MI, stroke, and mortality as compared with A, BB, or S independently. ACE-I did not demonstrate additional risk-reduction benefits.
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