SAGE Journals Online
Advertisement
Sign In to gain access to subscriptions and/or personal tools.

 

Advanced Search

Journal Navigation

Journal Home

Subscriptions

Archive

Contact Us

Table of Contents

Advertisement

Sign In to gain access to subscriptions and/or personal tools.
Seminars in Cardiothoracic and Vascular Anesthesia
This Article
Right arrow Abstract Freely available
Right arrow Free Full Text (Free PDF) Free
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Saved Citations
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Request Reprints
Right arrow Add to My Marked Citations
Citing Articles
Right arrow Citing Articles via Google Scholar
Right arrow Citing Articles via Scopus
Google Scholar
Right arrow Articles by London, M. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by London, M. J.
Social Bookmarking
Add to CiteULike   Add to Complore   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati   Add to Twitter  
What's this?

Beta-Blockade in the Perioperative Period: Where Do We Stand After All the Trials?

Martin J. London, MD

University of California, San Francisco; Department of Anesthesia, Veterans Affairs Medical Center, San Francisco, CA londonm{at}anesthesia.ucsf.edu

Perioperative myocardial infarction following noncardiac surgery is a complex process with a variety of proposed etiologic factors. Perioperativeb-blockade has been reported to reduce perioperative myocardial infarction and cardiac death, with possible direct effects on longer-term outcome, particularly after vascular surgery. Despite two high-profile studies that have pushed this topic into the mainstream of medicine, the number of patients studied and outcomes observed remains limited, especially for a therapy recommended for widespread adoption in millions of patients globally. Observational analyses, small meta-analyses, and newer randomized trial data (primarily in abstract format) suggest the therapy is of benefit in high-risk patients, whereas in patients at intermediate or low risk, it is either mildly efficacious or neutral in effect. Adverse effects appear to be limited to the expected primary hemodynamic side effects of bradycardia and hypotension, although a suggestion of increased mortality has been reported in one observational analysis in the lowest-risk group.b-Blockade may be associated with reduction in length of stay and reduced analgesic requirements, although these effects remain controversial. A single mega-trial being conducted outside of the United States with a target goal of 10,000 patients is ongoing and promises to provide definitive data within the next few years. Ongoing research into various etiologies of perioperative myocardial infarction and other medications with potential efficacy in this setting, including the important antiplatelet agents, must also be considered in developing recommendations for widespread adoption of perioperativeb-blockade.

References

  • Faraday N, Martinez EA, Scharpf RB, et al: Platelet gene polymorphisms and cardiac risk assessment in vascular surgical patients. Anesthesiology 101:1291-1297, 2004.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • Landesberg G, Mosseri M, Zahger D, et al: Myocardial infarction after vascular surgery: The role of prolonged stress-induced, ST depression-type ischemia. J Am Coll Cardiol 37:1839-1845, 2001.[Abstract/Free Full Text]
  • Le Manach Y, Perel A, Coriat P, et al: Early and delayed myocardial infarction after abdominal aortic surgery. Anesthesiology 102:885-891, 2005.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • McCrath DJ, Cerboni E, Frumento RJ, et al: Thromboelastography maximum amplitude predicts postoperative thrombotic complications including myocardial infarction. Anesth Analg 100:1576-1583, 2005.[Abstract/Free Full Text]
  • Gokce N, Keaney JF Jr, Hunter LM, et al: Predictive value of noninvasively determined endothelial dysfunction for long-term cardiovascular events in patients with peripheral vascular disease. J Am Coll Cardiol 41:1769-1775, 2003.[Abstract/Free Full Text]
  • London MJ, Zaugg M, Schaub MC, et al: Perioperative beta-adrenergic receptor blockade: Physiologic foundations and clinical controversies. Anesthesiology 100:170-175, 2004.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • Kertai MD, Boersma E, Westerhout CM, et al: A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery. Eur J Vasc Endovasc Surg 28:343-352, 2004.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • O’Neil-Callahan K, Katsimaglis G, Tepper MR, et al: Statins decrease perioperative cardiac complications in patients undergoing noncardiac vascular surgery. The Statins for Risk Reduction in Surgery (StaRRS) study. J Am Coll Cardiol 45:336-342, 2005.[Abstract/Free Full Text]
  • Kim LJ, Martinez EA, Faraday N, et al: Cardiac troponin I predicts short-term mortality in vascular surgery patients. Circulation 106:2366-2371, 2002.[Abstract/Free Full Text]
  • Mangano DT, Layug EL, Wallace A, et al: Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 335:1713-1720, 1996.[Abstract/Free Full Text]
  • Poldermans D, Boersma E, Bax JJ, et al: The effect of bisoprolol on perioperative mortality and myocardial infarction in high-Risk patients undergoing vascular surgery. N Engl J Med 341:1789-1794, 1999.[Abstract/Free Full Text]
  • Wallace A, Layug B, Tateo I, et al: Prophylactic atenolol reduces postoperative myocardial ischemia. McSPI Research Group. Anesthesiology 88:7-17, 1998.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • Mangano DT, Browner WS, Hollenberg M, et al: Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. N Engl J Med 323:1781-1788, 1990.[Abstract]
  • Devereaux PJ, Yusuf S, Yang H, et al: Are the recommendations to use perioperative beta-blocker therapy in patients undergoing noncardiac surgery based on reliable evidence? CMAJ 171:245-247, 2004.[Free Full Text]
  • Boersma E, Poldermans D, Bax JJ, et al: Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. JAMA 285:1865-1873, 2001.[Abstract/Free Full Text]
  • Sear JW, Foex P, Howell SJ: Effect of chronic intercurrent medication with beta-adrenoceptor blockade or calcium channel entry blockade on postoperative silent myocardial ischaemia. Br J Anaesth 84:311-315, 2000.[Abstract/Free Full Text]
  • Eagle KA, Berger PB, Calkins H, et al: ACC/AHA guideline update for perioperative cardiovascular evaluation for non-cardiac surgery—executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 105:1257-1267, 2002.[Free Full Text]
  • Van Den Kerkhof EG, Milne B, Parlow JL: Knowledge and practice regarding prophylactic perioperative beta blockade in patients undergoing noncardiac surgery: A survey of Canadian anesthesiologists. Anesth Analg 96:1558-1565, 2003.[Abstract/Free Full Text]
  • London MJ, Itani KM, Perrino AC, Jr, et al: Perioperative beta-blockade: A survey of physician attitudes in the Department of Veterans Affairs. J Cardiothorac Vasc Anesth 18:14-24, 2004.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • Grupper A, Brezis M: Resistance to use of perioperative beta-blockers: A no-man's land. Arch Intern Med 165:347-347,2005.[Free Full Text]
  • Lindenauer PK, Fitzgerald J, Hoople N, et al: The potential preventability of postoperative myocardial infarction: Underuse of perioperative beta-adrenergic blockade. Arch Intern Med 164:762-766, 2004.[Abstract/Free Full Text]
  • Lindenauer PK, Pekow P, Wang K, et al: Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery. JAMA 291:2092-2099, 2004.[Abstract/Free Full Text]
  • Lindenauer PK, Pekow P, Wang K, et al: Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med 353:349-361, 2005.[Abstract/Free Full Text]
  • Lee TH, Marcantonio ER, Mangione CM, et al: Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery. Circulation 100:1043-1049, 1999.[Abstract/Free Full Text]
  • Blackstone EH: Comparing apples and oranges. J Thorac Cardiovasc Surg 123:8-15, 2002.[Free Full Text]
  • Bohm M, Maack C, Wehrlen-Grandjean M, et al: Effect of bisoprolol on perioperative complications in chronic heart failure after surgery (Cardiac Insufficiency Bisoprolol Study II (CIBIS II)). Z Kardiol 92:668-676, 2003.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • Stevens RD, Burri H, Tramer MR: Pharmacologic myocardial protection in patients undergoing noncardiac surgery: A quantitative systematic review. Anesth Analg 97:623-633, 2003.[Abstract/Free Full Text]
  • Devereaux PJ, Beattie WS, Choi PT, et al: How strong is the evidence for the use of perioperative beta blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials. BMJ 331:313-321, 2005.[Abstract/Free Full Text]
  • London MJ, Zaugg M, Schaub MC, et al: A large trial is vital to prove perioperative beta-blockade effectiveness and safety before widespread use. Anesthesiology 101:804-805,2004.[CrossRef][Web of Science]
  • Juul AB, Wetterslev J, Kofoed-Enevoldsen A, et al: The Diabetic Postoperative Mortality and Morbidity (DIPOM) trial: Rationale and design of a multicenter, randomized, placebo-controlled, clinical trial of metoprolol for patients with diabetes mellitus who are undergoing major noncardiac surgery. Am Heart J 147:677-683, 2004.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • Yang H, Raymer K, Butler R, et al: Metoprolol after vascular surgery (MaVS). Can J Anesth 51 (Suppl 1):A7-A7, 2004.
  • Brady AR, Gibbs JS, Greenhalgh RM, et al: Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: Results of a randomized double-blind controlled trial. J Vasc Surg 41:602-609, 2005.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • Zaugg M, Tagliente T, Lucchinetti E, et al: Beneficial effects from beta-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology 91:1674-1686, 1999.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • COMMIT: Study Website: Design and Results. http://www.ctsu.ox.ac.uk/ccs2/. (2005).
  • ACC/AHA/AHRQ/CMS/JCAHO Practice Advisory: Commitment to respond to COMMIT/CCS-2 Trial results. http://www.americanheart.org (2005).
  • Wijeysundera DN, Naik JS, Beattie WS: Alpha-2 adrenergic agonists to prevent perioperative cardiovascular complications: A meta-analysis. Am J Med 114:742-752, 2003.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • Kamp O, Sieswerda GT, Visser CA: Comparison of effects on systolic and diastolic left ventricular function of nebivolol versus atenolol in patients with uncomplicated essential hypertension. Am J Cardiol 92:344-348, 2003.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • Witchitz S, Cohen-Solal A, Dartois N, et al: Treatment of heart failure with celiprolol, a cardioselective beta blocker with beta-2 agonist vasodilatory properties. The CELICARD Group. Am J Cardiol 85:1467-1471, 2000.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  • Tardif J-C: Ivabradine in clinical practice: benefits of If inhibition. Eur Heart J Suppl 7:H29-H32, 2005.
  • Boyce SW, Bartels C, Bolli R, et al: Impact of sodium-hydrogen exchange inhibition by cariporide on death or myocardial infarction in high-risk CABG surgery patients: Results of the CABG surgery cohort of the GUARDIAN study. J Thorac Cardiovasc Surg 126:420-427, 2003.[Abstract/Free Full Text]

Seminars in Cardiothoracic and Vascular Anesthesia, Vol. 10, No. 1, 17-23 (2006)
DOI: 10.1177/108925320601000105
Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to Technorati Technorati   Add to Twitter Twitter    What's this?



This Article
Right arrow Abstract Freely available
Right arrow Free Full Text (Free PDF) Free
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Saved Citations
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Request Reprints
Right arrow Add to My Marked Citations
Citing Articles
Right arrow Citing Articles via Google Scholar
Right arrow Citing Articles via Scopus
Google Scholar
Right arrow Articles by London, M. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by London, M. J.
Social Bookmarking
Add to CiteULike   Add to Complore   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati   Add to Twitter  
What's this?

Advertisement