Source: Stroke  |  Posted 8 years ago

By Bonnie Darves

NEW ORLEANS, LA -- April 27, 2004 -- A combination of beta-blocker therapy and noninvasive testing, preceded by an extensive workup, is the best approach to evaluate and prepare patients with cardiac risk for upcoming noncardiac surgery, said Gino Merli, MD, director of internal medicine, Jefferson Medical College, Philadelphia, Pennsylvania.

Beta blockers should not be used in lieu of noninvasive testing for those patients, Dr. Merli added during a presentation here April 24th at the American College of Physicians - American Society of Internal Medicine Annual Session. Dr. Merli stressed the importance of using both the perioperative beta blocker course and performing stress testing with concurrent cardiac imaging to ensure that patients are not only candidates for the planned surgery but also that all cardiac risk factors are fully addressed before the event.

"Beta blocker therapy [alone] is not an acceptable alternative to noninvasive testing," he said, because that testing helps identify patients who are at risk for ischemia, for whom these agents may be critical to reducing mortality.

Dr. Merli outlined the criteria for use of beta blockers, and recommended them for patients who are undergoing high-risk surgery or who have 1 or more of the following conditions or risk factors:

? Ischemic heart disease, including a history of myocardial infarction, angina, positive stress test findings, or Q waves on electrocardiogram.

? Previous angioplasty or coronary artery bypass grafting, or who have chest pain that might be caused by ischemia.

? Cerebrovascular disease, including a history of transient ischemic attacks (TIAs) or prior stroke.

? Confirmed diabetes requiring insulin therapy, as well as chronic renal insufficiency.

When deciding which patients should undergo stress testing, Dr. Merli said physicians should consult the updated guidelines from the American College of Cardiology/American Heart Association (ACC/AHA), which call for testing patients who have any of the following clinical predictors: class I or II angina; prior heart attack; diabetes; or heart failure. In addition, patients with poor overall functional capacity and those undergoing high-risk or prolonged surgical procedures should receive stress testing with concurrent imaging.

When surgery is not emergently required, patients with mild to moderate hypertension should postpone the procedure until hypertension is under control. In a recommendation not supported by new or past clinical studies, Dr. Merli also urged postponement in patients whose hypertension may be the result of a pheochromocytoma, hyperaldosteronism, renal artery stenosis, or aortic coarctation. "If the surgery is urgent or emergent, beta blockers in patients for whom there are no contraindications may be 1 approach to [obtain] blood pressure control," Dr. Merli said.

He stressed the importance of a thorough, extensive preoperative workup based on the ACC/AHA clinical predictor model for perioperative cardiovascular risk. In addition, he urged physicians to ensure they have an understanding of how patients on current anticoagulant therapy should be counseled before surgery regarding possible temporary discontinuation of the treatment. While procedures associated with a high risk of bleeding -- such as polypectomy and endoscopic sphincterotomy -- require warfarin discontinuation, the anticoagulants can be safely continued for a wide range of ophthalmic, dermatological, and joint and soft tissue procedures.

He referred attendees to the current ACC recommendations on the topic, which include a detailed list of procedures for which warfarin can be safely continued and those calling for anticoagulant discontinuation. While the list provides good guidance, Dr. Merli said that "clinical judgment should prevail" in cases that are not clear cut.

[Presentation Title: Preoperative Evaluation of the Patient With Cardiac Risk for Non-Cardiac Surgery.]