Beta-Blockade: Minimizing Cardiac Risk During Non-Cardiac Surgery

An estimated 6 million people undergo non-cardiac surgery each year, and up to a quarter of these procedures (eg, major intra-abdominal, thoracic vascular, and orthopedic procedures) are associated with significant risk of perioperative cardiovascular morbidity and mortality. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) issued a practice guideline for the utilization of β-blockade in non-cardiac surgery. The update, published in the November 24, 2009 issue of Circulation and the Journal of the American College of Cardiology, identifies important new information regarding the risks and benefits of perioperative β-blockade. “Non-cardiac surgery represents a stress to the heart, particularly if the procedure is high risk or if patients have underlying risk factors for cardiac complications,” says Kirsten E. Fleischmann, MD, MPH, who chaired the committee that generated the focused update. As the aging population rises and the number of non-cardiac surgeries performed in them continues to increase, steps must be taken to minimize the risk of cardiac complications associated with these surgeries. Clinical Trial Evidence Drives Update Another impetus for the ACCF/AHA update was the publication of new randomized trial data, most notably the POISE (PeriOperative Ischemic Evaluation) and DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography)-IV trials. POISE confirmed that β-blocker therapy reduces perioperative cardiac events, but also clarified that routine perioperative β-blockade—particularly in fixed, higher-dose regimens initiated the day of surgery—was associated with risk. In POISE, the reduction in cardiac events was offset by a higher risk of stroke and death when using fixed higher-doses of metoprolol started on the day of surgery. The DECREASE-IV trial assigned intermediate cardiac risk patients to...