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.
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Figure 1 Flow chart of the study. Cardiac risk factors included: age over 70 years, angina pectoris, prior myocardial infarction on the basis of history or a finding of pathologic Q waves on electrocardiography, compensated congestive heart failure or a history of congestive heart failure, current treatment for diabetes mellitus, renal dysfunction (serum creatinine >160 µmol/l), and prior stroke or transient ischemic attack. Patients with 1 or 2 cardiac risk factors were randomly (1:1) assigned to cardiac testing or no testing. Test results were classified as no ischemia, limited ischemia, and extensive ischemia. Patients with extensive ischemia were considered for coronary revascularization.
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Figure 2 Heart rate at the screening visit, at the day of hospital admission, and immediately before surgery in patients allocated to cardiac testing (left) or no testing (right). Heart rate values are presented as beats/min (bpm).
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Figure 3 Incidence of cardiac death or myocardial infarction (MI) during 3-year follow-up according to the number of cardiac risk factors (left) and allocated strategy in patients with 1 or 2 cardiac risk factors only (right). The incidence of cardiac death or MI was associated with the number of cardiac risk factors at screening (log-rank p < 0.001). There was no significant difference in the long-term incidence of cardiac events between patients allocated to cardiac testing or no testing (log-rank p = 0.30).
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Figure 4 Cumulative distribution of the heart rate before surgery (left) and the relation between heart rate and perioperative cardiovascular events (right). For this analysis we included patients with 1 to 2 risk factors. The hazard ratio was adjusted for clinical risk factors. bpm = beats/min.
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