First ESC Guidelines for Noncardiac Surgery Support Use of Beta Blockers

September 08, 2009

September 8, 2009 (Barcelona, Spain )– The European Society of Cardiology has issued its first-ever guidelines on the management of cardiac risk in noncardiac surgery [1,2]. The guidance focuses on practical, stepwise evaluation of the patient, stratifying the cardiac risk and attempting to reduce unnecessary preoperative testing, which is not only costly but delays surgery, Dr Don Poldermans (Erasmus Medical Center, Rotterdam, the Netherlands) told a press conference at the European Society of Cardiology 2009 Congress.

Poldermans explained that cardiac events are the major cause of morbidity and mortality in patients undergoing noncardiac surgery and that cardiologists are confronted every day with decisions about how to reduce the risk of these events without unnecessarily delaying surgery. The risk of cardiac complications depends on the condition of the patient before surgery, the prevalence of heart disease, and the size and duration of the operation to be undertaken.

"We are in need of guidelines to give improved care to these patients, and with this new advice, we believe we can improve not only postoperative outcomes but also long-term outcomes," he said. There is an emphasis on medical therapy, reducing preoperative testing and preoperative coronary revascularization, and there are clear recommendations for beta-blocker, statin, aspirin, clopidogrel, and ACE-inhibitor use, with the aim of making noncardiac surgery an opportunity to improve secondary prevention, he added.

Specific recommendations address antiplatelet therapy and the titration of beta blockers, "because those two are the most difficult to handle," he said. The issue of whether to use beta blockers perioperatively in patients undergoing noncardiac surgery has been extremely controversial in the past few years, as reported by heartwire . The new European guidance recommends that a low dose of beta blocker be started prior to surgery, with the dose titrated to achieve a heart rate (HR) of between 60 and 70 beats per minute (bpm).

European beta blocker recommendations "thoughtful"

Poldermans expanded upon the discussion about beta-blocker use: "The key thing in these patients is to reduce heart rate, not to block heart-rate response. If, for instance, during surgery you have a bleed, then you want the heart to pump up to maintain blood pressure, so if we overdo it, we take back the beta blocker. In the POISE study [the trial that first raised concerns about perioperative beta-blocker use] they started beta blockade four hours prior to surgery and gave a fixed, high dose in patients who were, on average, 70 years old, and some of those patient developed bleeding during surgery.

"We recommend starting low-dose bisoprolol or low-dose metoprolol one month prior to surgery, or at the very least one week before surgery. We want to start earlier--we want to have the patient hemodynamically stable--and we will not overdose the patient."

Commenting on the new European guidelines, Dr Sidney Smith (University of North Carolina, Chapel Hill) said they "are very similar to the existing guidelines in the US published in 2007, with the major difference centering on the recommendation for beta blockers."

He told heartwire : "We've really gone from the feeling that beta blockers would benefit everyone to studies showing that lower-risk patients sometimes do worse on beta blockers and then to discussions about how they should be given. POISE was very controversial. You have to look at the risk of the group that went in to POISE and how they were treated. What is emerging from these data and guidelines is that beta blockers given earlier and titrated to [achieve an] HR of 60 to 65 bpm in groups that are at high risk undergoing high-risk surgery appears to have a benefit.

"The Europeans are recommending that they be given [at least] a week before surgery, and there are some very thoughtful recommendations about titrating to heart rate, so I think these guidelines have done a good job of looking at the evidence," Smith added.

The US is currently in the process of preparing a focused update on the use of beta blockers perioperatively in noncardiac surgery, with the expectation that they will be issued by the end of this year, he said, adding: "I can't comment on what they ultimately will say, because at some point in the review process things could change."

Noncardiac surgery: A unique opportunity to intervene

In Europe, there are approximately 40 million surgical procedures performed per year, with around 400 000 perioperative MIs occurring (1%)--although this is believed to be an underestimate--and 133 000 cardiovascular deaths (0.3%), Poldermans noted. And these figures look set to rise as more and more elderly people come for surgery, with more comorbidities, so they often also have cardiac disease, neurological disease, or renal dysfunction--hence the need for guidelines to improve the care given to these patients, he said.

The first stage is to preoperatively assess people with the aim of stratifying patients according to risk of cardiac events, Poldermans said. "We can stratify patients into low risk--in these people we can skip all the testing"--intermediate, in whom risk-reduction strategies are recommended, or high risk. The last--"those with multiple risk factors scheduled for high-risk surgery--should undergo echocardiography or exercise stress testing," he said.

Emphasis is also put on restricting the use of preventive coronary revascularization, he explained, because this is rarely indicated just to get the patient through surgery, and antiplatelet therapy such as clopidogrel complicates perioperative management.

The overall aim is to perform a thorough preoperative cardiac risk evaluation in a patient, which offers a unique opportunity to identify and treat risk factors, with the initiation of lifestyle changes and medical therapy for secondary prevention. "Once the patient has survived surgery, usually the surgeon says the medications have done their job and he stops all the medication, but of course he did not perform surgery on the heart, so we always suggest continuing all the medication because it improves both perioperative and late outcomes," Poldermans explained.

Because the causes of perioperative cardiac events are complex, a combination of beta blockers, statins, aspirin, and ACE inhibitors "are probably the best medical options," he said.

As well as the specific recommendations on beta blockers, there is also guidance on statin use in the new European advisory, with statins with a long half-life or extended-release formulations being recommended to bridge the period immediately after surgery, when oral intake is not feasible. And "aspirin is now a clear indication; we do not discontinue aspirin therapy" except in those in whom hemostasis is difficult to control during surgery, Poldermans noted.

Smith said one of the things he found most heartening in the new European guidelines was the effort made to reduce the amount of preoperative testing that is performed.

"I'm very impressed--in each of these guidelines there is a structured approach to evaluating these patients and treating them, and in general it centers on looking at the risk of the patient and the procedure and in every one of these situations, we came out with fewer tests. Here you have a group of cardiologists getting together and recommending fewer tests."

DECREASE III trial published

Rotterdam, the Netherlands – Patients undergoing vascular surgery who are not already taking a statin gain an almost 50% reduction in myocardial ischemia as well as reductions in cardiovascular death/nonfatal MI with perioperative use of extended-release fluvastatin (Lescol XL, Novartis), results of the Dutch Echographic Cardiac Risk Evaluation Applying Stress Echo III (DECREASE III) show [3]. The findings, which were first reported at the European Society of Cardiology 2008 Congress, as reported by heartwire , have just been published in the September 3, 2009 issue of the New England Journal of Medicine, by Dr Olaf Schouten (Erasmus Medical Center, Rotterdam, the Netherlands) and colleagues.

In vascular surgery, cardiovascular mortality is a bigger problem than in general surgery, per se, the authors explain, with a 2% rate of cardiovascular death, much of which is due to perioperative MI. There was a clear reduction in the primary end point among those taking fluvastatin--30 days after surgery, 27 patients in the statin group (10.8%) had myocardial ischemia compared with 47 (19.0%) in the placebo group (hazard ratio 0.55; p=0.01). Poldermans, the senior author on the paper, told heartwire at the time of the presentation last year: "If you want to improve outcomes [in patients with peripheral arterial disease], it's wise to start [statins] early before surgery because you have additional gain. That's something people should know . . . although [the patients] might not have an increased cholesterol level, they still benefit from statins."

DECREASE III was supported by unrestricted research grants from Novartis. Poldermans reports receiving consulting fees from Medtronic, Novartis, and Merck and grant support from Novartis. Disclosures for other DECREASE III authors are listed in the paper.

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