Nonselective Compared With Selective α-Blockade Is Associated With Less Intraoperative Hypertension in Patients With Pheochromocytomas and Paragangliomas: A Retrospective Cohort Study With Propensity Score Matching

Abstract

Background: Both selective and nonselective α-blockade are used for preoperative preparation in patients with pheochromocytomas and paragangliomas (PPGLs). However, the effects of different types of α-blockade on perioperative outcomes remain inconclusive. This study was designed to assess the association between the choice of α-blockade and the amount of intraoperative hypertension in patients undergoing surgery for PPGLs. METHODS: In this propensity-matched retrospective cohort study, data of patients who received either selective or nonselective α-blockade preoperatively and underwent surgery for PPGLs were collected. The primary end point was the time-weighted average above the systolic blood pressure (SBP) of 160 mm Hg (TWA-SBP >160 mm Hg), which was calculated as the total area of the SBP-time curve above the SBP of 160 mm Hg and divided by anesthesia duration. RESULTS: A total of 286 patients were included in analysis; of them, 156 received selective α-blockade and 130 nonselective α-blockade. After propensity score matching, 89 patients remained in each group. Patients who received nonselective α-blockade had a lower TWA-SBP >160 (median 0.472 mm Hg, interquartile range [IQR], 0.081–1.300) versus those who received selective α-blockade (median 1.114 mm Hg, IQR, 0.162–2.853; median difference −0.391, 95% confidence interval [CI], −0.828 to −0.032; P = .016); they also had a lower highest SBP during surgery (193 ± 24 mm Hg versus 205 ± 34 mm Hg; mean difference −12, 95% CI, −20 to −3; P = .008). Postoperative outcomes did not differ significantly between the 2 groups. CONCLUSIONS: For patients undergoing surgery for PPGLs, preoperative nonselective α-blockade was associated with less intraoperative hypertension when compared with selective α-blockade.

Pre-Operative Selective vs Non-Selective α-Blockade in Pheochromocytoma–Paraganglioma Patients Undergoing Surgery: A Meta-Analysis

“…Of the 10 articles that met the inclusion criteria, one was randomized control trial, one prospective case-control study and the remaining eight were retrospective studies. [ 8 9 10 11 12 13 14 15 16 17 ] All 10 studies included in this review scored from 10 to 20 (out of 31) on the risk of bias assessment tool; most of the studies scored low on the power criterion as there was less number of patients included. On reporting and selection bias, all the studies scored an average or above average.…”

“…Kong et al . [ 16 ] performed a retrospective propensity-matched analysis involving 89 patients in each NSAB and SAB group. They reported that NSAB was superior in controlling intra-operative hypertension.…”

“…Four studies[ 8 9 11 16 ] concluded that NSAB was better over SAB in controlling intra-operative HDI. While two studies[ 14 15 ] reported SAB to be superior over NSAB in controlling intra-operative instability.…”

Risk factors for intraoperative complications in pheochromocytomas

“…Several retrospective studies have shown that alphaadrenergic receptor blockers are the first-choice drug to minimize perioperative complications (Kocak et al 2002, Weingarten et al 2010, Zhu et al 2010, Lenders et al 2014, Falhammar et al 2018, Buitenwerf et al 2020, Kong et al 2021. However, some authors described less severe hypotensive episodes and of shorter duration with calcium antagonists compared to alpha-blockade (Brunaud et al 2014).…”

Non-Selective Alpha-Blockers Provide More Stable Intraoperative Hemodynamic Control Compared with Selective Alpha1-Blockers in Patients with Pheochromocytoma and Paraganglioma: A Single-Center Retrospective Cohort Study with a Propensity Score-Matched Analysis from China

“…We identified 84 patients who were treated with non-selective α-adrenergic blockers and 117 patients with selective-1 α-adrenergic blockers. Finally, we successfully matched 62 pairs who had propensity scores of 0.04 (20% of the standard deviation of the overall propensity score) 17 based on the following patient characteristics: age, sex, BMI, comorbidities, typical symptoms, plasma catecholamine levels, maximum tumor diameter, pathological diagnosis, use of other antihypertensive drugs, use of β-blockers, preoperative volume expansion, systolic blood pressure one day before surgery, heart rate one day before surgery, ASA classification, duration of anesthesia, mode of anesthesia maintenance, surgical time, and surgical approach. After matching was completed, the absolute standardized differences of the matched variables were further calculated for assessment.…”