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

Leiden University, Leyden, South Holland, Netherlands
Journal of the American College of Cardiology (Impact Factor: 16.5). 09/2006; 48(5):964-9. DOI: 10.1016/j.jacc.2006.03.059
Source: PubMed


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).

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Available from: Bernard P Paelinck
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    • "Ninety-eight studies were screened, and of these, 2 met the inclusion criteria: DECREASE II [24] and Falcone et al [25]. These 2 randomised controlled trials examined preoperative stress testing for vascular surgery. "
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    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 a concise scientifically based guideline and commit to updating it responsibly.
    Full-text · Article · Mar 2014 · International journal of cardiology
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    • "The second multicenter Dutch Echoardiographic Cardiac Risk Evaluation study assessed the value of NIST in intermediate risk patients [9]. All patients received beta-blockers to achieve a resting heart rate of 60 to 65 beats/min. "
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    ABSTRACT: To identify the risk factors of major adverse cardiac event (MACE) in patients with chronic atherosclerotic lower extremity ischemia (CALEI) undergoing revascularization without noninvasive stress testing (NIST). From January 2007 to January 2012, patients with CALEI who underwent revascularization were retrospectively reviewed. Emergent operations, revision procedures for previous surgery, or patients with active cardiac conditions were excluded. NIST was not performed for patients without active cardiac conditions. Cardiac risk was categorized into low, intermediate and high risk, according to the Lee's revised cardiac risk index. MACE was defined as acute myocardial infarction or any cardiac death within 30 days after surgery. A total of 459 patients underwent elective lower extremity revascularization procedures (240 open surgeries, 128 endovascular procedures, and 91 hybrid surgeries). The treated lesions comprised of 18% aorto-iliac, 58% infrainguinal, and 24% combined lesions. With regard to cardiac risk, low-, intermediate- and high risks were 67%, 32% and 2%, respectively. MACE was developed in 7 patients (2%). High or intermediate risk group by the Lee's index was related to postoperative MACE. Subgroup analysis for open surgery or hybrid surgery group identified female gender as an independent risk factor of MACE (P = 0.049; odds ratio, 5.168; confidence interval, 1.011 to 26.423). The Lee's index was a useful predictor of MACE. MACE is more common in female patients than male patients after open or hybrid surgery. Routine preoperative NIST is not suggested for all patients undergoing revascularization for CALEI, especially for those in the low risk group.
    Full-text · Article · Mar 2013 · Journal of the Korean Surgical Society
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    • "For this reason, the stress thallium scan has been widely performed in patients with vascular surgery. However, it is not consistently predictive of risk [29-31]. "
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    ABSTRACT: Identification of patients at high risk for perioperative cardiac events (POCE) is clinically important. This study aimed to determine whether preoperative measurement of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) could predict POCE, and compared its predictive value with that of conventional cardiac risk factors and stress thallium scans in patients undergoing vascular surgery. Patients scheduled for non-cardiac vascular surgery were prospectively enrolled. Clinical risk factors were identified, and NT-proBNP levels and stress thallium scans were obtained. POCE was the composite of acute myocardial infarction, congestive heart failure including acute pulmonary edema, and primary cardiac death within 5 days after surgery. A modified Revised Cardiac Risk Index (RCRI) was proposed and compared with NT-proBNP; a positive result for ischemia and a significant perfusion defect (≥ 3 walls, moderate to severely decreased, reversible perfusion defect) on the thallium scan were added to the RCRI. A total of 365 patients (91% males) with a mean age of 67 years had a median NT-proBNP level of 105.1 pg/mL (range of quartile, 50.9 to 301.9). POCE occurred in 49 (13.4%) patients. After adjustment for confounders, an NT-proBNP level of > 302 pg/mL (odds ratio [OR], 5.7; 95% confidence interval [CI], 3.1 to 10.3; p < 0.001) and a high risk by the modified RCRI (OR, 3.9; 95% CI, 1.6 to 9.3; p = 0.002) were independent predictors for POCE. Comparison of the area under the curves for predicting POCE showed no statistical differences between NT-proBNP and RCRI. Preoperative measurement of NT-proBNP provides information useful for prediction of POCE as a single parameter in high-risk patients undergoing noncardiac vascular surgery.
    Full-text · Article · Sep 2012 · The Korean Journal of Internal Medicine
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