Should Major Vascular Surgery Be Delayed Because of Preoperative Cardiac Testing in Intermediate-Risk Patients Receiving Beta-Blocker Therapy With Tight Heart Rate Control?

Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands.
Journal of the American College of Cardiology (Impact Factor: 15.34). 09/2006; 48(5):964-9. DOI: 10.1016/j.jacc.2006.03.059
Source: PubMed

ABSTRACT According to the guidelines of the American College of Cardiology /American Heart Association (ACC/AHA), all patients scheduled for major vascular surgery who have clinical features associated with increased cardiac risk should undergo noninvasive cardiac stress-testing (1). Perioperative beta-blocker therapy is recommended for patients with inducible ischemia undergoing major vascular surgery. The guidelines also recommend coronary angiography for patients with high-risk noninvasive test results and myocardial revascularization in patients with prognostic high-risk anatomy in whom long-term outcome is likely to be improved. However, noninvasive testing might delay surgery and run the risk of aortic aneurysmal rupture or exacerbation of critical limb ischemia. Furthermore, a recent randomized, controlled trial of preoperative myocardial revascularization in vascular surgery patients showed no improvement in perioperative or long-term outcome associated with prophylactic revascularization (2).

Download full-text


Available from: Bernard P Paelinck, Jul 04, 2015
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Cardiologists frequently advise on perioperative care for non-cardiac surgery, and require guidance based on randomised controlled trials that are not discredited by misconduct or misreporting. Regional political bodies currently do not provide this. We therefore examined the credible randomised controlled trial (RCT) evidence on key cardiac perioperative questions which currently have 14 recommendations. Methods Three aspects of perioperative measures were considered: perioperative statins, preoperative stress-testing and perioperative beta-blockade. One author searched Pubmed for RCTs considering these topics. All authors independently assessed the RCTs and then collaboratively composed guidelines. Results Perioperative statin therapy has been examined by three RCTs, DECREASE III and IV which are discredited and a third containing serious inconsistencies undermining its validity. Preoperative stress testing has been examined by two RCTs: one discredited trial, DECREASE II, and a second which found no benefit. Perioperative beta blockade has been examined by eleven RCTs, two of which are discredited. The nine remaining trials together suggest that perioperative beta-blockade increases mortality. Conclusions When the non-credible RCTs are omitted, the evidence base on these three subjects is much smaller than previously believed: 14 recommendations can be replaced by 3. Current guideline arrangements collectively paralyse the numerous signatories from making urgent amendments after initial publication, even when important new information comes to light. Clinicians simply have to wait for the routine five-year expiry. We present in the accompanying document a concise scientifically-based guideline and commit to updating it responsibly.
    International journal of cardiology 03/2014; 172(1). DOI:10.1016/j.ijcard.2013.12.309 · 6.18 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Current efforts to improve the cost-effectiveness of health care focus on assessing accurately the value of technologically complex, costly medical treatments for individual patients and society. These efforts universally acknowledge that the determination of such value should incorporate information regarding the risks posed by a given treatment for an individual, but they typically overlook the implications for medical decision making that inhere in how notions of risk are understood and used in contemporary medical discourse. To gain perspective on how the hazards of surgery have been defined and redefined in medical thought, we examine changes over time in notions of risk related to operative care. We reviewed historical writings on risk assessment and patient selection for surgical procedures published between 1957 and 1997 and conducted informal interviews with experts. To examine changes attributable to advances in research on risk assessment, we focused on the period surrounding the 1977 publication of an influential surgical risk-stratification index. Writings before 1977 demonstrate a summative, global approach to patients as "good" or "poor" risks, without quantifying the likelihood of specific postoperative events. Beginning in the early 1980s, assessments of operative risk increasingly emphasized quantitative estimates of the probability of dysfunction of a specific organ system after surgery. This new approach to establishing surgical risk was consistent with concurrent trends in other domains of medicine. In particular, it emphasized a more "scientific," standardized approach to medical decision making over an earlier focus on individual physicians' judgment and professional authority. Recent writings on operative risk reflect a viewpoint that is more specific and, at the same time, more generic and fragmented than earlier approaches. By permitting the separation of multiple component hazards implicit in surgical interventions, such a viewpoint may encourage a distinct, permissive standard for surgical interventions that conflicts with larger policy efforts to promote cost-effective decision making by physicians and patients.
    Milbank Quarterly 03/2012; 90(1):135-59. DOI:10.1111/j.1468-0009.2011.00657.x · 5.06 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Given the increasing complexity of hospitalized patients and the increasing specialization among surgeons, there is greater reliance on hospitalists for preoperative assessment. Several institutions have developed surgery/medicine comanagement teams that jointly care for patients in the perioperative setting. Despite a growing body of evidence, it is important to recognize there are many gaps in the perioperative literature. This has led to considerable dependence on consensus statements and expert opinion when evaluating patients perioperatively. This review focuses on the preoperative cardiovascular and pulmonary evaluation of the hospitalized patient: the two systems responsible for the greatest morbidity and mortality. Prevention of postoperative venous thromboembolism and management of perioperative hyperglycemia are also discussed.
    Medical Clinics of North America 04/2008; 92(2):325-48, viii. DOI:10.1016/j.mcna.2007.10.003 · 2.80 Impact Factor