What pre-operative cardiac evaluation of patients undergoing intermediate-risk surgery is most appropriate?

Further data have shown increased mortality with perioperative beta blockade in low-risk patients. Most recently, an abstract from the largest randomized controlled trial to date, the POISE study, suggested that preoperative beta blockade decreased MI and cardiac death, but increased the risk of stroke and produced higher overall mortality.20

It is challenging to reconcile this newer evidence with the previous data. While it seems intuitive that blunting the catecholamine response would minimize cardiac workload and therefore decrease perioperative infarcts, surgical patients are also at risk for poor pain control, sepsis, hypovolemia, and venous thromboembolism. Beta blockade can obscure their clinical manifestations, delaying diagnosis or complicating therapy. Inconsistencies among studies and published guidelines make them difficult to apply broadly, particularly with the intermediate-risk patient. Finally, perioperative beta blockade is poorly defined in terms of timing of initiation, target heart rate, and duration of postoperative use.

Until more definitive trial data are published, it seems most prudent to continue beta-blockers in patients already using them. Start them as far in advance of surgery as possible in patients with high-risk features (such as a positive stress test). After surgery, pay close attention to volume status, pain, signs of sepsis, or other noncardiac complications.

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As per the 2007 ACC/AHA guidelines, this patient with one clinical risk factor (diabetes) and good functional capacity can proceed to the operating room without further intervention. While it is likely a patient with diabetes and hyperlipidemia has some degree of CAD, including possible vulnerable plaques, the best medical evidence offers little to decrease her operative cardiac risk. Perioperative beta blockade is not indicated at her level of risk (RCRI of one) given the inconsistent benefits and possible harm to patients like this seen in trials to date.

If she were limited in terms of functional capacity (i.e., less than four METS), the 2007 ACC/AHA algorithm suggests preoperative noninvasive testing “if it would change management.”

How might a positive stress test change management in this case? Revascularization with stenting in close proximity to noncardiac surgery is not safe, and there appears to be no benefit to preoperative revascularization before high-risk vascular surgery. However, ischemia on preoperative testing is an indication for a beta-blocker. A brief delay in her surgery to allow dose titration and use of telemetry monitoring after surgery would increase the safety of beta-blockers after surgery. How long to continue beta-blockers is an open question, but at least 30 days would seem adequate, tapering rather than abruptly discontinuing the dose. TH

Dr. Carter is an assistant professor of medicine at the University of Colorado Denver in the Section of Hospital Medicine, where he directs the Medicine Consult Service. Dr. Auerbach is an associate professor of medicine in residence, associate director of the general medicine research fellowship, director of quality improvement for the UCSF Department of Medicine, and director of the surgical care Improvement program at UCSF. His research interests include perioperative medicine and quality improvement.

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