Abstract
Purpose
To describe how we implemented a protocol for perioperative beta-blockade in patients with or at risk of coronary artery disease (CAD) undergoing major non-cardiac surgery and to present our results.
Methods
After institutional approval, from May 1999 to April 2001, patients with surgical and medical indications (CAD as indicated by previous myocardial infarction, typical angina or atypical angina with a positive stress test or at least two risk factors for CAD: age 65 yr, hypertension, smoking, high cholesterol, diabetes mellitus) for perioperative beta-blockade were identified preoperatively by anesthesiology and referred to the General Internal Medicine Service (MED), MED initiated patients on outpatient beta-blockers. The intraoperative anesthetic management was left to the discretion of the anesthesiologist. In the postanesthesia care unit (PACU), patients received iv metoprolol according to hemodynamic criteria, Postoperatively, patients were followed by MED for adverse cardiac events.
Results
Sixty-nine patients received perioperative beta-blockade, Preoperatively, 60% were started on metoprolol, 39% on atenolol and 1% on proprandol. In PACU, 42%, 9% and 38% of patients were given iv metoprolol 0, 5 and 10 mg respectively. One patient was given glycopyrrolate in the PACU for bradycardia and none received vasoactive or inotropic agents. Three patients (4.3%) had postoperative cardiac events.
Conclusions
With close collaboration between anesthesiologists, internists, PACU nurses and family physicians, a strategy for perioperative beta-blockade was implemented successfully in patients with cardiac risks. Beta-blockade was associated with few side effects and morbidities.
Résumé
Objectif
Décrire la mise en application d’un protocole de bêtablocage périopératoire chez des patients atteints, ou à risque, de coronaropathie (CP) devant subir une intervention non cardiaque majeure, et présenter nos résultats.
Méthode
Ayant reçu l’approbation de l’institution, les anesthésiologistes ont identifié, entre mai 1999 et avril 2001, les patients admissibles à un bêta-blocage périopératoire seion des indications médicales et chirurgicales (CP révélée par un infarctus du myocarde antérieur, angine typique ou atypique démontrée par une épreuve d’effort positive ou au moins deux facteurs de risque de CP : âge = 65 ans, hypertension, tabagisme, cholestérol élevé, diabète) et les ont été dirigés vers le General Internal Medicine Service (MED). Le MED a d’abord administré les bêta-bloqueurs en clinique externe. L’anesthésiologiste s’est chargé de la période peropératoire. À la salle de réveil (SDR), on a administré du métoprolol iv seion les critères hémodynamiques. Le MED a assuré un suivi postopératoire en raison de complications cardiaques possibles.
Résultats
Soixante-neuf patients ont reçu des bêta-bioqueurs périopératoires. Avant l’opération, 60% d’entre eux ont d’abord eu du métoprolol, 39% de l’aténoiol et 1% du propranolol. À la SDR, 42%, 9% et 38% des patients ont respectivement reçu 0, 5 et 10 mg de métoprolol iv. À la SDR, un patient a reçu du glycopyrrolate pour une bradycardie, mais aucun agent vasoactif ou inotrope n’a été donné. Trois patients (4,3%) ont eu des problèmes cardiaques postopératoires.
Conclusion
La collaboration entre anesthésiologistes, intemistes, personnel infirmier de la SDR et omnipraticiens a permis la mise en œuvre réussie d’une stratégie de bêta-blocage périopératoire chez des patients présentant des risques cardiaques. Peu de morbidité ou d’effets secondaires ont été associés au bêta-blocage.
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References
Mangano DT, Wong MG, London MJ, Tubau JF, Rapp JA. Perioperative myocardial ischemia in patients undergoing noncardiac surgery-II: incidence and severity during the 1st week after surgery. The Study of Perioperative Ischemia (SPI) Research Group. J Am Coll Cardiol 1991; 17: 851–7.
Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau TF, Tateo IM. Association of perioperative rnyocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group. N Engl J Med 1990; 323: 1781–8.
Mangano DT, Browner WS, Hollenberg M, Li J, Tatoe IM. Long-term cardiac prognosis following noncardiac surgery. JAMA 1992; 268: 233–9.
Browner WS, Li J, Mangano DT. In hospital and longterm mortality in male veterans following noncardiac surgery. The Study of Perioperative Ischemia Research Group. JAMA 1992; 268: 228–32.
Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 1996; 335: 1713–20.
Wallace A, Layug B, Tatoe I, et al. Prophylactic atenolol reduces postoperative myocardial ischemia. The McSPI Research Group. Anesthesiology 1998; 88: 7–17.
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. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 1999; 341: 1789–94.
Fleisher LA, Eagle KA. Lowering cardiac risk in noncardiac surgery. N Eng J Med 2001; 345: 1677–82.
Eagle KA, Berger PB, Calkins H, et al. ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac 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 2002; 105: 1257–67.
ISIS-I (First International Study of Infarct Survival) Collaborative Group. Randomized trial of intravenous atenolol among 16 027 cases of suspected acute myocardial infarction: ISIS-I. Lancet 1986; 2: 57–66.
ISIS-I (First International Study of Infarct Survival) Collaborative Group. Mechanisms for the early mortality reduction produced by beta-blockade started early in acute myocardial infarction: ISIS-I. Lancet 1988; 1: 921–3.
Anonymous. Metoprolol in acute myocardial infarction. Patients and methods. The MIAMI Trial Research Group. Am J Cardiol 1985; 56: 3G–9G.
Anonymous. Metoprolol in acute myocardial infarction (MIAMI). A randomised placebo-controlled internaltional trial. The MIAMI Trial Research Group. Eur Heart J 1985; 6: 199–226.
Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). J Am Coll Cardiol 1999; 33: 2092–197.
Shaw LJ, Eagle KA, Gersh BJ, Miller DD. Meta-analysis of intravenous dipyridamole-thallium-201 imaging (1984 to 1994) and dobutamine echocardiography (1991 to 1994) for risk stratification before vascular surgery. J Am Coll Cardiol 1996; 27: 787–98.
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Supported by the Department of Anesthesiology, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Armanious, S., Wong, D.T., Etchells, E. et al. Successful implementation of perioperative betablockade utilizing a multidisciplinary approach. Can J Anaesth 50, 131–136 (2003). https://doi.org/10.1007/BF03017844
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DOI: https://doi.org/10.1007/BF03017844