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β-Blockers and Cardiac Events in Noncardiac Surgery

β-Blockers and Cardiac Events in Noncardiac Surgery

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Publicado porChadi Alraies
Beta blockers are known for their cardioprotective properties when used in noncardiac surgeries. This was one of the main principles in the perioperative medicine. However, lately this concepts being questions and this cardio protective properties have almost fallen of the AHA/ACC guidelines giving the risk of increased mortality for patient using this medication around the surgery time.

POISE trial in 2008 was a landmark in the beta blockers literature which showed that beta blockers are not always safe and the use of this dug should me customized for each patient.

Mid 2009, Poldermans et al, showed that beta blockers is an effective medication if it is used in correct way and titrated gradually over time to make the real effect take place overtime.

In this slide show you I am reviewing the old and new literature and present the 2007 ACC/AHA perioperative guidelines and the level of evidence for this drug.

This topic is an interesting and hot topic and I hope this slide show will help you make the correct decision in your daily perioperative practice.

Let me know what you think
Beta blockers are known for their cardioprotective properties when used in noncardiac surgeries. This was one of the main principles in the perioperative medicine. However, lately this concepts being questions and this cardio protective properties have almost fallen of the AHA/ACC guidelines giving the risk of increased mortality for patient using this medication around the surgery time.

POISE trial in 2008 was a landmark in the beta blockers literature which showed that beta blockers are not always safe and the use of this dug should me customized for each patient.

Mid 2009, Poldermans et al, showed that beta blockers is an effective medication if it is used in correct way and titrated gradually over time to make the real effect take place overtime.

In this slide show you I am reviewing the old and new literature and present the 2007 ACC/AHA perioperative guidelines and the level of evidence for this drug.

This topic is an interesting and hot topic and I hope this slide show will help you make the correct decision in your daily perioperative practice.

Let me know what you think

More info:

Published by: Chadi Alraies on Sep 02, 2009
Copyright:Attribution Non-commercial

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Effect of Atenolol on Mortality and Cardiovascular
Morbidity after Noncardiac Surgery.
Mangano 1996

Mangano DT, Layug EL, Wallace A, et al; for Multicenter Study of Perioperative Ischemia Research Group. Effect of atenolol onmortality and
cardiovascular morbidity after noncardiac surgery. N Engl J Med. 1996;335:1713–1720.

Participants

200 patients.

Surgery

Elective non-cardiac surgery

Intervention

Atenolol(100mg PO or 10 IV) vs. placebo

Administration

Before anesthesia & Immediately after surgery for 7 days

Median follow-up

24 months

Primaryoutcome

composite all-cause mortality, MI, UA, CHF

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Mangano 1996

Overall Survivalin the Two Years after Noncardiac Surgery among 192 Patients in the Atenolol and
Placebo Groups Who Survived to Hospital Discharge.

68%

83%

P = 0.008

Mangano DT. N Engl J Med. 1996;335:1713–1720.

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Mangano 1996

Event-free Survivalin the Two Years after Noncardiac Surgery among 192 Patients in the Atenolol
and Placebo Groups Who Survived to Hospital Discharge. N Engl J Med. 1996;335:1713–1720.

79%

90%

Mangano DT, N Engl J Med. 1996;335:1713–1720.

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Mangano 1996

•In patients who have or are at risk for CAD +
noncardiac surgery, treatment with atenolol
reduce mortality and the incidence of MACE
for two years after surgery.

Mangano DT, N Engl J Med. 1996;335:1713–1720.

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The effect of bisoprolol on perioperative mortality and
myocardial infarction in high-risk patients undergoing
vascular surgery
Poldermans D 1999

Poldermans D, Boersma E, Bax JJ, et al; for Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography
Study Group. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular
surgery. N Engl J Med. 1999;341: 1789–1794.

Participants

112 patients.

Stress test

Positive dobutamine echocardiography

Surgery

Elective non-cardiac surgery

Intervention

Bisoprolol (5 mg titrated to 10mg) vs. placebo

Administration

Daily for 1 week before surgery and QD for 30 days post surgery.

Dose titration

Yes (1 week interval)

Median follow-up

24 months

Primaryoutcome

composite all-cause mortality, MI, UA, CHF

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Poldermans D,1999

Kaplan–Meier Estimates of the Cumulative Percentages of Patients Who Died of Cardiac Causes
or Had a Nonfatal Myocardial Infarction during the Perioperative Period.

Poldermans D,. N Engl J Med. 1999;341: 1789–1794.

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Poldermans D,1999

Poldermans D,. N Engl J Med. 1999;341: 1789–1794.

Bisoprolol reduces the perioperative incidence of
death from cardiac causes and nonfatal myocardial
infarction in high-risk patients who are undergoing
major vascular surgery.

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β-Blockers and Reduction of Cardiac Events in
Noncardiac Surgery
, scientific review. Auerbach 2002

Auerbach AD, Goldman L. Beta-Blockers and reduction of cardiac events in noncardiac surgery: scientific review. JAMA. 2002;287:1435–1444

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1. β-blockers work the best in high risk patients.
2.Need more studies for patients with stable coronary
disease and are undergoing elective surgery?

3.What is the optimal duration of therapy?
4.Which agent is the best?
5.When to start BB therapy?

Auerbach AD. JAMA. 2002;287:1435–1444

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Perioperative -blockade (POBBLE) for patients undergoing
infrarenal vascular surgery: Results of a randomized double-blind
controlled trial. Brady et al 2005, UK

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. 2005;41:602–609.

Participants

103 patients –median age 73 yrs

Surgery

Infrarenal vascular surgery

Intervention

Metoprolol (50 mg BID) vs. Placebo

Administration

Day before surgery twice daily & Continued for 7-14 days

Dose titration

No

Median follow-up

30 days

Primaryoutcome

composite all-cause mortality, MI, UA, CHF

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