What are the recommendations for the Aegean trial in terms of cardiovascular intervention and medication (e.g. aspirin, beta-blockers, statins)?

Recommendations for Cardiovascular Intervention and Medication in the AEGEAN Trial

The combination of aspirin, beta-blockers, and statins (ABBS therapy) is strongly recommended for high-risk patients undergoing major vascular surgery in the AEGEAN trial, as this combination therapy has demonstrated superior 30-day and 12-month risk reduction benefits for myocardial infarction, stroke, and mortality compared to using these medications independently. 1

Medication Recommendations

Aspirin

• Low-dose aspirin (81mg) should be continued perioperatively in patients already taking it, with decisions based on individual bleeding risk versus cardiovascular risk 2
• Aspirin is associated with improved 12-month survival (HR 0.35,95% CI 0.24-0.53) in high-risk vascular surgery patients 1
• Caution should be exercised in patients with increased bleeding risk, as aspirin is an NSAID that may cause stomach bleeding 3

Beta-Blockers

• Beta-blockers should be continued perioperatively in patients already taking them 2
• If initiating beta-blockers, doses should be carefully titrated to heart rate and blood pressure to avoid hypotension 2
• Beta-blockers reduce myocardial injury but require careful monitoring as resultant hypotension may contribute to increased all-cause mortality and stroke risk 2
• Beta-blocker therapy is associated with improved 12-month survival (HR 0.65,95% CI 0.43-1.0) in high-risk vascular surgery patients 1

Statins

• Statins should be continued perioperatively in all patients already taking them 2
• Current evidence suggests statins are cardioprotective during the perioperative period 2
• Statin therapy is strongly associated with improved 12-month survival (HR 0.36,95% CI 0.25-0.53) in high-risk vascular surgery patients 1
• Statins should be initiated early, regardless of lipid levels, in patients with cardiovascular disease or at high risk 4

Combination Therapy Approach

ABBS Therapy (Aspirin + Beta-Blocker + Statin)

• The incidence of myocardial infarction is 3-fold lower (2.5% vs. 7.8%) with ABBS therapy compared to patients not receiving this combination 1
• 12-month mortality is 8-fold lower with ABBS therapy compared to non-ABBS therapy (5.9% vs. 37.5%) 1
• The combined use of aspirin, statin, and blood pressure-lowering agents is associated with a lower risk of myocardial infarction (HR 0.68), ischemic cerebrovascular events (HR 0.37), and all-cause mortality (HR 0.69) 5

ACE Inhibitors/ARBs Considerations

• ACE inhibitors did not demonstrate additional risk-reduction benefits beyond ABBS therapy in high-risk vascular surgery patients (HR 0.80,95% CI 0.54-1.19) 1
• For patients with diabetes, ACE inhibitors or angiotensin receptor blockers should be included as part of the treatment regimen, particularly for those with albuminuria 6
• The combination of an ACE inhibitor and calcium channel blocker provides complementary mechanisms of action with additive blood pressure lowering effects 7

Timing and Implementation

• For patients hospitalized with a cardiovascular event, statins should be started in the hospital, regardless of lipid levels 4
• Beta-blockers should be initiated with careful dose titration to avoid hypotension 6
• Long-term management should include aggressive and extensive risk factor modification 6
• Patients with diabetes should be treated as if they have preexisting cardiovascular disease 4

Pitfalls and Caveats

• Abrupt discontinuation of beta-blockers perioperatively can lead to rebound tachycardia and hypertension 6
• Initiating ACE inhibitors before beta-blockers may make it impossible to subsequently prescribe a beta-blocker due to hypotension 6
• The combination of an ACE inhibitor with an angiotensin receptor blocker should be avoided as this increases cardiovascular and renal risk 7
• Monitor for postural hypotension, particularly in elderly patients receiving multiple antihypertensive medications 6
• Aspirin may cause severe stomach bleeding, especially in patients who are over 60, have had stomach ulcers, take blood thinners or steroids, or consume alcohol regularly 3

By implementing this comprehensive cardiovascular medication regimen in the AEGEAN trial, significant reductions in morbidity and mortality can be achieved for patients undergoing major vascular procedures.