CLINICAL RESEARCH
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, Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo Study Group
* Departments of Anesthesiology
Vascular Surgery
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.
|
Abbreviations and Acronyms
| | ACC/AHA = American College of Cardiology/ American Heart Association | | CI = confidence interval | | MI = myocardial infarction | | OR = odds ratio |
|
Related Article
-
Any Need for Preoperative Cardiac Testing in Intermediate-Risk Patients With Tight Beta-Adrenergic Blockade?
- Kim A. Eagle and Wei C. Lau
J. Am. Coll. Cardiol. 2006 48: 970-972.
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
L. A. Verduzco and G. K. Lighthall
The Evolving Role of Preoperative Testing in Vascular Surgery Patients: Can a Little Knowledge Be Dangerous?
Seminars in Cardiothoracic and Vascular Anesthesia,
September 1, 2011;
15(3):
75 - 84.
[Abstract]
[PDF]
|
|
|
|
|
|
|
N. Troisi, R. Pulli, W. Dorigo, P. Lo Sapio, and C. Pratesi
Preoperative cardiac assessment in patients undergoing major vascular surgery
Vascular,
August 1, 2011;
19(4):
178 - 186.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. N. Wijeysundera, W. S. Beattie, K. Karkouti, M. D. Neuman, P. C. Austin, and A. Laupacis
Association of echocardiography before major elective non-cardiac surgery with postoperative survival and length of hospital stay: population based cohort study
BMJ,
June 30, 2011;
342(jun30_1):
d3695 - d3695.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Santini, M. Gasparini, M. Landolina, M. Lunati, A. Proclemer, L. Padeletti, D. Catanzariti, G. Molon, G. L. Botto, L. La Rocca, et al.
Device-Detected Atrial Tachyarrhythmias Predict Adverse Outcome in Real-World Patients With Implantable Biventricular Defibrillators
J. Am. Coll. Cardiol.,
January 11, 2011;
57(2):
167 - 172.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Chua
The evolving role of molecular imaging for coronary artery disease: where do we stand today?
Heart Asia,
July 5, 2010;
1(1):
1 - 5.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Cassar, D. Poldermans, C. S. Rihal, and B. J. Gersh
The management of combined coronary artery disease and peripheral vascular disease
Eur. Heart J.,
July 1, 2010;
31(13):
1565 - 1572.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. N Wijeysundera, W S. Beattie, P. C Austin, J. E Hux, and A. Laupacis
Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study
BMJ,
January 28, 2010;
340(jan28_3):
b5526 - b5526.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Cheng
Preoperative non-invasive stress testing
BMJ,
January 18, 2010;
340(jan18_1):
b5401 - b5401.
[Full Text]
|
|
|
|
|
|
|
J-H Choi, D K Cho, Y-B Song, J-Y Hahn, S Choi, H-C Gwon, D-K Kim, S H Lee, J K Oh, and E-S Jeon
Preoperative NT-proBNP and CRP predict perioperative major cardiovascular events in non-cardiac surgery
Heart,
January 1, 2010;
96(1):
56 - 62.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
American College of Cardiology Foundation, American Heart Association Task Force on Practice, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interve, Society for Vascular Medicine, Society for Vascular Surgery, L. A. Fleisher, et al.
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery
J. Am. Coll. Cardiol.,
November 24, 2009;
54(22):
e13 - e118.
[Full Text]
[PDF]
|
|
|
|
|
|
|
American College of Cardiology Foundation, American Heart Association Task Force on Practice, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interve, Society for Vascular Medicine, Society for Vascular Surgery, K. E. Fleischmann, et al.
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade
J. Am. Coll. Cardiol.,
November 24, 2009;
54(22):
2102 - 2128.
[Full Text]
[PDF]
|
|
|
|
|
|
|
2009 WRITING GROUP TO REVIEW NEW EVIDENCE AND UPDA, K. E. Fleischmann, J. A. Beckman, C. E. Buller, H. Calkins, L. A. Fleisher, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al.
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Circulation,
November 24, 2009;
120(21):
2123 - 2151.
[Full Text]
[PDF]
|
|
|
|
|
|
|
2007 WRITING COMMITTEE MEMBERS, L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, et al.
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Circulation,
November 24, 2009;
120(21):
e169 - e276.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Authors/Task Force Members, D. Poldermans, J. J. Bax, E. Boersma, S. De Hert, E. Eeckhout, G. Fowkes, B. Gorenek, M. G. Hennerici, B. Iung, et al.
Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA)
Eur. Heart J.,
November 2, 2009;
30(22):
2769 - 2812.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. FLEISHER
Cardiac risk stratification for noncardiac surgery: Update from the American College of Cardiology/American Heart Association 2007 guidelines
Cleveland Clinic Journal of Medicine,
November 1, 2009;
76(Suppl_4):
S9 - S15.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Brunelli, A. Charloux, C. T. Bolliger, G. Rocco, J-P. Sculier, G. Varela, M. Licker, M. K. Ferguson, C. Faivre-Finn, R. M. Huber, et al.
ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy)
Eur. Respir. J.,
July 1, 2009;
34(1):
17 - 41.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Suttner, J. Boldt, A. Mengistu, K. Lang, and J. Mayer
Influence of continuous perioperative beta-blockade in combination with phosphodiesterase inhibition on haemodynamics and myocardial ischaemia in high-risk vascular surgery patients
Br. J. Anaesth.,
May 1, 2009;
102(5):
597 - 607.
[Abstract]
[PDF]
|
|
|
|
|
|
|
D. Poldermans, O. Schouten, J. Bax, and T. A. Winkel
Reducing cardiac risk in non-cardiac surgery: evidence from the DECREASE studies
Eur. Heart J. Suppl.,
March 1, 2009;
11(suppl_A):
A9 - A14.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Hoeks and D. Poldermans
CHAPTER 34 Non-cardiac Surgery in Cardiac Patients
ESC Textbook of Cardiovascular Medicine,
January 1, 2009;
2(1):
med-9780199566990-chapter - med-9780199566990-chapter.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. D. Kertai, C. M. Westerhout, K. S. Varga, G. Acsady, and J. Gal
Dihydropiridine calcium-channel blockers and perioperative mortality in aortic aneurysm surgery
Br. J. Anaesth.,
October 1, 2008;
101(4):
458 - 465.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. M. Biccard and S. J. Howell
Calcium channel blockers, beta-blockers, and perioperative cardiovascular stability
Br. J. Anaesth.,
October 1, 2008;
101(4):
439 - 441.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Current Guidelines for Preoperative Management Leave Me Wanting More
Journal Watch Hospital Medicine,
August 25, 2008;
2008(825):
1 - 1.
[Full Text]
|
|
|
|
|
|
|
B. HARTE and A. K. JAFFER
Perioperative beta-blockers in noncardiac surgery: Evolution of the evidence
Cleveland Clinic Journal of Medicine,
July 1, 2008;
75(7):
513 - 519.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Sicari, P. Nihoyannopoulos, A. Evangelista, J. Kasprzak, P. Lancellotti, D. Poldermans, J.-U. Voigt, J. L. Zamorano, and on behalf of the European Association of Echocardi
Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC)
Eur Heart J Cardiovasc Imaging,
July 1, 2008;
9(4):
415 - 437.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Gregoratos
Current Guideline-Based Preoperative Evaluation Provides the Best Management of Patients Undergoing Noncardiac Surgery
Circulation,
June 17, 2008;
117(24):
3134 - 3144.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. S. Brett
Coronary Assessment Before Noncardiac Surgery: Current Strategies Are Flawed
Circulation,
June 17, 2008;
117(24):
3145 - 3151.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Poldermans, S. E. Hoeks, and H. H. Feringa
Pre-Operative Risk Assessment and Risk Reduction Before Surgery
J. Am. Coll. Cardiol.,
May 20, 2008;
51(20):
1913 - 1924.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. Leff and T. E. Finucane
Gizmo Idolatry
JAMA,
April 16, 2008;
299(15):
1830 - 1832.
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. S. Beattie, D. N. Wijeysundera, K. Karkouti, S. McCluskey, and G. Tait
Does Tight Heart Rate Control Improve Beta-Blocker Efficacy? An Updated Analysis of the Noncardiac Surgical Randomized Trials
Anesth. Analg.,
April 1, 2008;
106(4):
1039 - 1048.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Developed in Collaboration With the American Socie, WRITING COMMITTEE MEMBERS, L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, et al.
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)
Anesth. Analg.,
March 1, 2008;
106(3):
685 - 712.
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. M. Biccard, J. W. Sear, and P. Foex
Meta-analysis of the effect of heart rate achieved by perioperative beta-adrenergic blockade on cardiovascular outcomes
Br. J. Anaesth.,
January 1, 2008;
100(1):
23 - 28.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Mantha, J. Foss, J. E. Ellis, and M. F. Roizen
Intense Cardiac Troponin Surveillance for Long-Term Benefits Is Cost-Effective in Patients Undergoing Open Abdominal Aortic Surgery: A Decision Analysis Model
Anesth. Analg.,
November 1, 2007;
105(5):
1346 - 1356.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al.
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery
J. Am. Coll. Cardiol.,
October 23, 2007;
50(17):
1707 - 1732.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al.
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery
J. Am. Coll. Cardiol.,
October 23, 2007;
50(17):
e159 - e242.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al.
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)
Circulation,
October 23, 2007;
116(17):
e418 - e500.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al.
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)
Circulation,
October 23, 2007;
116(17):
1971 - 1996.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. J. Gibbons, P. A. Araoz, and E. E. Williamson
The Year in Cardiac Imaging
J. Am. Coll. Cardiol.,
September 4, 2007;
50(10):
988 - 1003.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. W. Harrington and M. T. Munekata
Update in General Internal Medicine
Ann Intern Med,
July 17, 2007;
147(2):
104 - 116.
[Full Text]
[PDF]
|
|
|
|
|
|
|
O. Schouten, L. A. Fleisher, M. J. London, H. H. H. Feringa, J. J. Bax, and D. Poldermans
Perioperative {beta}-Blockade: Still Not Enough for Adequate Cardioprotection!
Anesth. Analg.,
July 1, 2007;
105(1):
279 - 280.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. E. Hoeks, J. J. Bax, and D. Poldermans
Indications of prophylactic coronary revascularization in patients undergoing major vascular surgery: the saga continues
Eur. Heart J.,
March 1, 2007;
28(5):
519 - 521.
[Full Text]
[PDF]
|
|
|
|
|
|
|
ADDITIONAL ARTICLES ABSTRACTED IN ACP JOURNAL CLUB
Evid. Based Med.,
February 1, 2007;
12(1):
30 - 30.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. N. DeMaria, O. Ben-Yehuda, G. K. Feld, G. S. Ginsburg, B. H. Greenberg, W. Y.W. Lew, J. A.C. Lima, A. S. Maisel, J. Narula, D. J. Sahn, et al.
Highlights of the Year in JACC 2006
J. Am. Coll. Cardiol.,
January 30, 2007;
49(4):
509 - 527.
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. A. Herzog
Kidney disease in cardiology
Nephrol. Dial. Transplant.,
January 1, 2007;
22(1):
43 - 46.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Fleisher
Perioperative {beta}-Blockade: How Best to Translate Evidence into Practice
Anesth. Analg.,
January 1, 2007;
104(1):
1 - 3.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Preoperative Cardiac Testing for Intermediate-Risk Patients?
Journal Watch (General),
November 29, 2006;
2006(1129):
1 - 1.
[Full Text]
|
|
|
|
|
|
|
K. A. Eagle and W. C. Lau
Any Need for Preoperative Cardiac Testing in Intermediate-Risk Patients With Tight Beta-Adrenergic Blockade?
J. Am. Coll. Cardiol.,
September 5, 2006;
48(5):
970 - 972.
[Full Text]
[PDF]
|
|
|
|
