CLINICAL RESEARCH: CORONARY ARTERY DISEASE
Should Major Vascular Surgery Be Delayed Because of Preoperative Cardiac Testing in Intermediate-Risk Patients Receiving Beta-Blocker Therapy With Tight Heart Rate Control?
Don Poldermans, MD, PhD*,*,
Jeroen J. Bax, MD, PhD ,
Olaf Schouten, MD ,
Aleksandar N. Neskovic, MD, PhD ,
Bernard Paelinck, MD, PhD||,
Guido Rocci, MD, PhD¶,
Laura van Dortmont, MD, PhD#,
Anai E.S. Durazzo, MD, PhD**,
Louis L.M. van de Ven, MD, PhD,
Marc R.H.M. van Sambeek, MD, PhD,
Miklos D. Kertai, MD, PhD*,
Eric Boersma, PhD for the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo Study Group
* Department of Anesthesiology, Erasmus Medical Center, Rotterdam, the Netherlands
Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
# Department of Vascular Surgery, Vlietland Hospital, Schiedam, the Netherlands
Merck BV, Amsterdam, the Netherlands
Dedinje Cardiovascular Institute, Belgrade University School of Medicine, Belgrade, Serbia and Montenegro
|| Department of Cardiology, University of Antwerp, Antwerp, Belgium
¶ Department of Cardiology, University of Bologna, Bologna, Italy
** Vascular Surgery Section, Department of Surgery, Health and Medical Sciences Sector, Lusiada Foundation, Santos, São Paulo, Brazil.
Manuscript received January 27, 2006;
revised manuscript received March 7, 2006,
accepted March 17, 2006.
* Reprint requests and correspondence: Dr. Don Poldermans, Room H921, Department of Anesthesiology, Erasmus Medical Center, 3015 GD Rotterdam, the Netherlands. (Email: d.poldermans{at}erasmusmc.nl).
OBJECTIVES: The purpose of this study was to assess the value of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate (HR) control scheduled for major vascular surgery.
BACKGROUND: Treatment guidelines of the American College of Cardiology/American Heart Association recommend cardiac testing in these patients to identify subjects at increased risk. This policy delays surgery, even though test results might be redundant and beta-blockers with tight HR control provide sufficient myocardial protection. Furthermore, the benefit of revascularization in high-risk patients is ill-defined.
METHODS: All 1,476 screened patients were stratified into low-risk (0 risk factors), intermediate-risk (1 to 2 risk factors), and high-risk ( 3 risk factors). All patients received beta-blockers. The 770 intermediate-risk patients were randomly assigned to cardiac stress-testing (n = 386) or no testing. Test results influenced management. In patients with ischemia, physicians aimed to control HR below the ischemic threshold. Those with extensive stress-induced ischemia were considered for revascularization. The primary end point was cardiac death or myocardial infarction at 30-days after surgery.
RESULTS: Testing showed no ischemia in 287 patients (74%); limited ischemia in 65 patients (17%), and extensive ischemia in 34 patients (8.8%). Of 34 patients with extensive ischemia, revascularization before surgery was feasible in 12 patients (35%). Patients assigned to no testing had similar incidence of the primary end point as those assigned to testing (1.8% vs. 2.3%; odds ratio [OR] 0.78; 95% confidence interval [CI] 0.28 to 2.1; p = 0.62). The strategy of no testing brought surgery almost 3 weeks forward. Regardless of allocated strategy, patients with a HR <65 beats/min had lower risk than the remaining patients (1.3% vs. 5.2%; OR 0.24; 95% CI 0.09 to 0.66; p = 0.003).
CONCLUSIONS: Cardiac testing can safely be omitted in intermediate-risk patients, provided that beta-blockers aiming at tight HR control are prescribed.
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Abbreviations and Acronyms
| | ACC/AHA = American College of Cardiology/ American Heart Association | | CI = confidence interval | | MI = myocardial infarction | | OR = odds ratio |
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