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Β-Blocker–Associated Risks in Patients with Uncomplicated Hypertension Undergoing Noncardiac Surgery

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Β-Blocker–Associated Risks in Patients with Uncomplicated Hypertension Undergoing Noncardiac Surgery Supplementary Online Content Jørgensen ME, Hlatky MA, Køber L, et al. β-Blocker–associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. Published online October 5, 2015. doi:10.1001/jamainternmed.2015.5346 eTable 1. Variable coding and definitions eTable 2. Use of beta blocker subtypes in the study population eTable 3. Distribution of type of surgery stratified by beta blocker use eTable 4. Distribution of key variables in patients with and without missing values eFigure 1. Secondary outcomes (individual MACE components) by antihypertensive drug regimen eFigure 2. Risks of MACE and mortality including patients treated with metoprolol or atenolol only eFigure 3. Patients with a diagnosis of hypertension and one-drug antihypertensive treatment eFigure 4. Main results adjusted for type of surgery in 17 categories eFigure 5. Risks associated with each study drug eFigure 6. Main results adjusted for alcohol and smoking with imputation for missing values eFigure 7. Analyses including patients on a 4-drug antihypertensive regimen eFigure 8. Estimates for other variables from the main model This supplementary material has been provided by the authors to give readers additional information about their work. Table of Contents eTable 1 ‐ Variable coding and definitions* ...................................................................................................... 3 eTable 2 – Use of beta blocker subtypes in the study population. ................................................................... 5 © 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 eTable 3 – Distribution of type of surgery stratified by beta blocker use. ........................................................ 6 eTable 4 – Distribution of key variables in patients with and without missing values. .................................... 7 eFigure 1 – Secondary outcomes (individual MACE components) by antihypertensive drug regimen. ........... 8 eFigure 2 – Risks of MACE and mortality including patients treated with metoprolol or atenolol only. ......... 9 eFigure 3 – Patients with a diagnosis of hypertension and one‐drug antihypertensive treatment. .............. 10 eFigure 4 – Main results adjusted for type of surgery in 17 categories. ......................................................... 11 eFigure 5 – Risks associated with each study drug. ........................................................................................ 12 eFigure 6 – Main results adjusted for alcohol and smoking with imputation for missing values. .................. 13 eFigure 7 – Analyses including patients on a 4‐drug antihypertensive regimen. ........................................... 14 eFigure 8 – Estimates for other variables from the main model. ................................................................... 15 © 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 eTable 1 ‐ Variable coding and definitions* Variable Coding and definitions Pharmacotherapy ATC code Beta blockers C07 RAS inhibitors C09 Calcium antagonists C08 Thiazides C03A Aldosterone antagonists C03D Digoxin C01AA Vitamin‐K anatagonists B01AA Lipid lowering therapy C10A Clopidogrel B01AC04 Glucose lowering agents A10 Loop diuretics C03CA01 RAS inhibitors and calcium antagonist combination C09DX01, C09DB01 therapya RAS inhibitors and thiazides C09DA, C09BA combination therapya Beta blockers and thiazides C07B combination therapya Comorbidity ICD‐10 code Ischemic stroke I63, I64 Acute myocardial infarction I21 Chronic obstructive pulmonary disease J42, J44 Anemia D60‐D69 Cancer C00‐C97 Renal disease N03, N04, N17, N18, N19, R34, I12, I13 Rheumatologic disease M05, M06, M32, M33, M34, M353 Peripheral artery disease I70, I74 Liver disease K70‐K77, B150, B160, B190 Diabetesb E10‐E14 (without E109, E119, E129, E139) Chronic heart failurec I42, I50, I110, J819 Ischemic heart disease I20, I23, I24, I25, Atrial fibrillation I48 Surgery category NCSP code Ear/nose/throat KD Minor orthopedic KNC, KND, KNH Major orthopedic KN (except KNC, KND, KNH) Abdominal (bowel) KJC, KJC, KJF, KJG, KJH Abdominal (non‐bowel) KJ (except KJC, KJF, KJG, KJH) Breast KH Plastic KQ Endocrine KB Eye KC Female reproductive KL Male reproductive KKD, KKE, KKF, KKG Intracranial KAA Neurological KA (Except KAA) Non‐arterial vessels KPH, KPJ Arterial vessels KP (except KPH, KPJ) © 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Thoracic/pulmonary KG Urology KK (except KKD, KKE, KKF, KKG) Surgery risk Surgery subtypes Low risk Breast, plastic, endocrine, and eye Elevated risk Ear/nose/throat, major orthopedic, minor orthopedic, abdominal, female reproductive, male reproductive, intracranial, neurological, non‐arterial vessels, thoracic/pulmonary, urology and arterial vessel surgery (exceptions: endoscopic orthopedic procedures and peripheral nerve surgery were low‐risk) *Footnote: aTreatment with a combination drug translated into treatment with two individual antihypertensive drugs. bDiabetes defined as present diagnosis or from use of glucose lowering agents. cChronic heart failure defined as present diagnosis or from use of loop diuretics. ATC code, Anatomical Therapeutic Classification System. ICD‐10 code, International Classification of Disease 10th edition. NCSP code, NOMESCO’s Classification of Surgical Procedures (Danish version). © 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 eTable 2 – Use of beta blocker subtypes in the study population. Beta blocker subtypes Patients, n (%) Proportion of beta ‐ main cohort. blocker treated patients, % No beta blocker 40,676 (73.5) NA Atenolol 2,422 (4.4) 16.5 Bisoprolol 707 (1.3) 4.8 Carvedilol 974 (1.8) 6.7 Metoprolol 9,302 (16.8) 63.5 Nebivolol 62 (0.1) 0.4 Pindolol 118 (0.2) 0.8 Propranolol 954(1.7) 6.5 Labetalol 105 (0.2) 0.7 Total 55,320 ( 100) 100 © 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 eTable 3 – Distribution of type of surgery stratified by beta blocker use. Type of surgery With beta Without beta Type of surgery With beta Without beta n(%) n(%) blockers blockers blockers blockers n=14,644 n=40,676 n=14,644 n=40,676 Ear/nose/throat 193 (1.3) 540 (1.3) Male reproductive 138 (0.9) 503 (1.2) Minor orthopedic 1,471 (10.0) 4,027 (9.9) Intracranial 191 (1.3) 479 (1.2) Major orthopedic 5,069 (34.6) 15,138 (37.2) Neurological 670 (4.6) 1,870 (4.6) Abdominal (bowel) 636 (4.3) 1,635 (4.0) Non‐arterial vessels 577 (3.9) 1,381 (3.4) Breast 293 (2.0) 695 (1.7) Arterial vessels 244 (1.7) 561 (1.4) Plastic 768 (5.2) 1,905 (4.7) Thoracic/pulmonary 146 (1.0) 413 (1.0) Endocrine 143 (1.0) 341 (0.8) Urology 930 (6.4) 2,514 (6.2) Abdominal (non‐ 1,736 (11.9) 5,016 (12.3) Female 1,119 (7.6) 2,741 (6.7) bowel) reproductive Eye 320 (2.2) 917 (2.3) © 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 eTable 4 – Distribution of key variables in patients with and without missing values. No missing in alcohol Missing in alcohol No missing in smoking Missing in smoking Age (Mean, years) 65.9 66.1 65.7 66.5 Gender (% female) 41.1 39.6 41.3 39.3 Beta blocker (% treated) 26.4 26.7 26.1 27.5 Urgency (% acute) 20.8 23.8 20.2 24.9 Surgery risk 86.6 82.5 86.9 82.7 (% elevated). © 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 eFigure 1 – Secondary outcomes (individual MACE components) by antihypertensive drug regimen. A - 30-day Cardiovascular Death Odds ratios (95% CI) Events/sample size RAS inhibitors + thiazides 1.00 (ref) 87/20745 Beta blocker + RAS inhibitors 3.50 (2.36-5.20) 39/2789 Beta blocker + calcium antagonists 2.76 (1.72-4.43) 24/1878 Beta blocker + thiazides 2.25 (1.48-3.42) 32/3427 Beta blocker + 2 others 1.23 (0.82-1.85) 37/6550 RAS inhibitors + calcium antagonists 1.29 (0.85-1.97) 33/6055 Three others than beta blockers 0.82 (0.54-1.25) 35/9248 Calcium antagonists + thiazides 1.04 (0.66-1.65) 29/4628 0,1 1 10 Odds ratios (95% CI) B - 30-day Non-fatal stroke Odds ratios (95% CI) Events/sample size RAS inhibitors + thiazides 1.00 (ref) 40/20745 Beta blocker + RAS inhibitors 0.52 (0.16-1.68) 3/2789 Beta blocker + calcium antagonists 1.69 (0.75-3.79) 7/1878 Beta blocker + thiazides 0.75 (0.29-1.91) 5/3427 Beta blocker + 2 others 1.32 (0.76-2.32) 19/6550 RAS inhibitors + calcium antagonists 1.19 (0.66-2.16) 15/6055 Three others than beta blockers 0.83 (0.46-1.48) 17/9248 Calcium antagonists + thiazides 1.44 (0.79-2.63) 15/4628 0,1 1 10 Odds ratios (95% CI) C - 30-day non-fatal AMI Odds ratios (95% CI) Events/sample size RAS inhibitors + thiazides 1.00 (ref) 34/20745 Beta blocker + RAS inhibitors 0.96 (0.34-2.71) 4/2789 Beta blocker + calcium antagonists 1.24 (0.44-3.52) 4/1878 Beta blocker + thiazides 0.77 (0.27-2.17) 4/3427 Beta blocker + 2 others 1.07 (0.55-2.07) 15/6550 RAS inhibitors + calcium antagonists 0.67 (0.29-1.51) 7/6055 Three others than beta blockers 1.46 (0.86-2.47) 25/9248 Calcium antagonists + thiazides 0.53 (0.21-1.37) 5/4628 0,1 1 10 Odds ratios (95% CI) © 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 eFigure 2 – Risks of MACE and mortality including patients treated with metoprolol or atenolol only. Only atenolol 30-day MACE Odds
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