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Optimizing Long-term Cardiac Management After Major Vascular Surgery
Role of  -Blocker Therapy, Clinical Characteristics, and Dobutamine Stress Echocardiography to Optimize Long-term Cardiac Management After Major Vascular Surgery
Miklos D. Kertai, MD, DSc;
Eric Boersma, PhD;
Jeroen J. Bax, MD, PhD;
Ian R. Thomson, MD;
Maarten J. Cramer, MD;
Louis L. M. van de Ven, MD, PhD;
Michaël G. Scheffer, MD;
Giuseppe Trocino, MD;
Carlo Vigna, MD;
Hubert F. Baars, MD;
Hero van Urk, PhD;
Jos R. T. C. Roelandt, MD, PhD;
Don Poldermans, MD; for the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) Study Group
Arch Intern Med. 2003;163:2230-2235.
Background Survivors of major vascular surgery are at increased risk of late cardiac complications.
Objective To examine the cardioprotective effect of  -blockers.
Methods A follow-up study was conducted in 1286 patients who survived surgery for at least 30 days. Patients were screened for cardiac risk factors and dobutamine stress echocardiography (DSE) results; 1034 patients (80%) underwent preoperative DSE, and 370 (29%) received -blockers. The main outcome measure was late cardiac death or myocardial infarction.
Results Seventy-four patients (5.8%) had late cardiac events. Cardiac event rates in patients with 0, 1 to 2, and 3 or more risk factors were 1.6%, 4.7%, and 19.2%, respectively. In patients without risk factors, -blockers were associated with improved event-free survival (2.8% vs 0%), and DSE had no additional prognostic value. In patients with 1 to 2 risk factors, the presence of ischemia during DSE increased cardiac events from 3.9% to 9.8%. However, if patients with ischemia were treated with -blockers, the risk decreased to 7.2%. In patients with 3 or more risk factors, DSE and -blockers stratified patients into intermediate- and high-risk groups. In patients without ischemia, -blockers reduced the cardiac event rate from 15.1% to 9.5%, whereas the cardioprotective effect was limited in patients with 3 or more risk factors and positive DSE findings.
Conclusions Long-term -blocker use is associated with a reduction in the cardiac event rate, except for patients with 3 or more risk factors and positive findings on DSE.
From the Departments of Cardiology (Drs Kertai, Boersma, Bax, van de Ven, and Roelandt) and Vascular Surgery (Drs van Urk and Poldermans), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Anesthesiology, University of Manitoba, Winnipeg (Dr Thomson); Department of Vascular Surgery, University Hospital Utrecht, Utrecht, the Netherlands (Dr Cramer); Sint Clara Ziekenhuis, Rotterdam (Dr Scheffer); Department of Cardiology, San Gerardo Hospital, Monza, Italy (Dr Trocino); Department of Cardiology, Instituto di Ricovero e Cura a Carattere Scientifico Hospital, San Giovanni Rotondo, Italy (Dr Vigna); and Department of Cardiology, Twee Steden Ziekenhuis, Tilburg, the Netherlands (Dr Baars).
A complete listing of the DECREASE Study Group members was published previously (N Engl J Med. 1999;341:1789-1794).
The authors have no relevant financial interest in this article.
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