β-Blocker Use May Preclude Preop Stress Testing

WAIKOLOA, HAWAII — Patients with low to moderate cardiac risk who receive targeted β-blocker therapy may not need to undergo preoperative stress testing before undergoing major vascular surgery/amputation, according to a new study presented at the annual meeting of the Western Vascular Society.

Anesthesiologists typically require a preoperative stress test in patients at low to intermediate risk of cardiac events, although recent evidence has found that such testing does not provide a benefit for such patients.

“Despite the literature, the American Heart Association has published a series of guidelines for preoperative cardiac risk assessment; it continues to recommend stress testing for a significant number of patients,” said Dr. Arezou Yaghoubian, a resident in the department of surgery at Harbor-UCLA Medical Center, Torrance, Calif. “As a result, many anesthesiologists won't take patients to surgery unless they are cardiac cleared, and many cardiologists won't clear patients for surgery without stress testing.”

The purpose of this study was to assess whether preoperative cardiac stress testing is needed in low- to intermediate-risk patients who receive targeted β-blocker therapy prior to major vascular surgery or lower extremity amputation. The primary end point was a composite measure of adverse cardiac outcomes. The study had both prospective and retrospective components.

Between the years 2004 and 2006, 100 consecutive prospectively enrolled patients who were scheduled to undergo major vascular surgery/lower-extremity amputation were given targeted β-blocker therapy but no preoperative cardiac stress testing or coronary revascularization.

“[Patients] were given metoprolol at 25 mg b.i.d. and had their dose titrated to an ideal target heart rate of 50–60 beats per minute,” Dr. Yaghoubian said. This was achieved in 24% of patients. Failure to achieve the target did not preclude surgery.

Another 80 control patients who had undergone similar procedures between 1999 and 2003 were identified retrospectively, she explained, adding: “Preoperative cardiac stress testing was utilized in 14% of the retrospective patients.” β-Blockade was given to 61% of retrospective patients.

“The primary outcome of this study was an adverse cardiac event,” she said, “either within the hospital or within 30 days of discharge.”

As for results, prospectively enrolled patients had a cardiac complication rate of 2%, compared with 10% of retrospective patients, a significant difference (P = .02).

Nobody died in either group. Multivariate analysis of the data found a significantly lower rate of cardiac complications in prospective patients, compared with retrospective ones (P = .003).

“In conclusion, in low- to intermediate-risk patients undergoing major vascular surgery and lower-extremity amputation, preoperative, targeted β-blockade is feasible in a short period of time,” Dr. Yaghoubian said.

“The findings of this study suggest that routine use of targeted β-blockade lowers cardiac morbidity and may even obviate the need for preoperative stress testing,” she said.

WAIKOLOA, HAWAII — Patients with low to moderate cardiac risk who receive targeted β-blocker therapy may not need to undergo preoperative stress testing before undergoing major vascular surgery/amputation, according to a new study presented at the annual meeting of the Western Vascular Society.

Anesthesiologists typically require a preoperative stress test in patients at low to intermediate risk of cardiac events, although recent evidence has found that such testing does not provide a benefit for such patients.

“Despite the literature, the American Heart Association has published a series of guidelines for preoperative cardiac risk assessment; it continues to recommend stress testing for a significant number of patients,” said Dr. Arezou Yaghoubian, a resident in the department of surgery at Harbor-UCLA Medical Center, Torrance, Calif. “As a result, many anesthesiologists won't take patients to surgery unless they are cardiac cleared, and many cardiologists won't clear patients for surgery without stress testing.”

The purpose of this study was to assess whether preoperative cardiac stress testing is needed in low- to intermediate-risk patients who receive targeted β-blocker therapy prior to major vascular surgery or lower extremity amputation. The primary end point was a composite measure of adverse cardiac outcomes. The study had both prospective and retrospective components.

Between the years 2004 and 2006, 100 consecutive prospectively enrolled patients who were scheduled to undergo major vascular surgery/lower-extremity amputation were given targeted β-blocker therapy but no preoperative cardiac stress testing or coronary revascularization.

“[Patients] were given metoprolol at 25 mg b.i.d. and had their dose titrated to an ideal target heart rate of 50–60 beats per minute,” Dr. Yaghoubian said. This was achieved in 24% of patients. Failure to achieve the target did not preclude surgery.

Another 80 control patients who had undergone similar procedures between 1999 and 2003 were identified retrospectively, she explained, adding: “Preoperative cardiac stress testing was utilized in 14% of the retrospective patients.” β-Blockade was given to 61% of retrospective patients.

“The primary outcome of this study was an adverse cardiac event,” she said, “either within the hospital or within 30 days of discharge.”

As for results, prospectively enrolled patients had a cardiac complication rate of 2%, compared with 10% of retrospective patients, a significant difference (P = .02).

Nobody died in either group. Multivariate analysis of the data found a significantly lower rate of cardiac complications in prospective patients, compared with retrospective ones (P = .003).

“In conclusion, in low- to intermediate-risk patients undergoing major vascular surgery and lower-extremity amputation, preoperative, targeted β-blockade is feasible in a short period of time,” Dr. Yaghoubian said.

“The findings of this study suggest that routine use of targeted β-blockade lowers cardiac morbidity and may even obviate the need for preoperative stress testing,” she said.

WAIKOLOA, HAWAII — Patients with low to moderate cardiac risk who receive targeted β-blocker therapy may not need to undergo preoperative stress testing before undergoing major vascular surgery/amputation, according to a new study presented at the annual meeting of the Western Vascular Society.

Anesthesiologists typically require a preoperative stress test in patients at low to intermediate risk of cardiac events, although recent evidence has found that such testing does not provide a benefit for such patients.

“Despite the literature, the American Heart Association has published a series of guidelines for preoperative cardiac risk assessment; it continues to recommend stress testing for a significant number of patients,” said Dr. Arezou Yaghoubian, a resident in the department of surgery at Harbor-UCLA Medical Center, Torrance, Calif. “As a result, many anesthesiologists won't take patients to surgery unless they are cardiac cleared, and many cardiologists won't clear patients for surgery without stress testing.”

The purpose of this study was to assess whether preoperative cardiac stress testing is needed in low- to intermediate-risk patients who receive targeted β-blocker therapy prior to major vascular surgery or lower extremity amputation. The primary end point was a composite measure of adverse cardiac outcomes. The study had both prospective and retrospective components.

Between the years 2004 and 2006, 100 consecutive prospectively enrolled patients who were scheduled to undergo major vascular surgery/lower-extremity amputation were given targeted β-blocker therapy but no preoperative cardiac stress testing or coronary revascularization.

“[Patients] were given metoprolol at 25 mg b.i.d. and had their dose titrated to an ideal target heart rate of 50–60 beats per minute,” Dr. Yaghoubian said. This was achieved in 24% of patients. Failure to achieve the target did not preclude surgery.

Another 80 control patients who had undergone similar procedures between 1999 and 2003 were identified retrospectively, she explained, adding: “Preoperative cardiac stress testing was utilized in 14% of the retrospective patients.” β-Blockade was given to 61% of retrospective patients.

“The primary outcome of this study was an adverse cardiac event,” she said, “either within the hospital or within 30 days of discharge.”

As for results, prospectively enrolled patients had a cardiac complication rate of 2%, compared with 10% of retrospective patients, a significant difference (P = .02).

Nobody died in either group. Multivariate analysis of the data found a significantly lower rate of cardiac complications in prospective patients, compared with retrospective ones (P = .003).

“In conclusion, in low- to intermediate-risk patients undergoing major vascular surgery and lower-extremity amputation, preoperative, targeted β-blockade is feasible in a short period of time,” Dr. Yaghoubian said.

“The findings of this study suggest that routine use of targeted β-blockade lowers cardiac morbidity and may even obviate the need for preoperative stress testing,” she said.