Prevention of acute coronary events in noncardiac surgery: β-blocker therapy and coronary revascularization

Abstract

During major vascular surgery, patients are at high risk for developing myocardial infarction and myocardial ischemia, and two risk-reduction strategies can be considered prior to surgery: pharmacological treatment and prophylactic coronary revascularization. β-blockers are established therapeutic agents for patients with hypertension, heart failure and coronary artery disease. There is still considerable debate concerning the protective effect of β-blocker therapy towards perioperative coronary events, which will be outlined in this article. Two randomized, controlled trials suggest that coronary revascularization of cardiac-stable patients provides no benefits in the postoperative outcomes. In the current American College of Cardiology/American Heart Association guidelines for ‘Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery’, routine prophylactic coronary revascularization is not recommended in patients with stable coronary artery disease. However, a recent retrospective, observational study suggests that intermediate-risk patients may benefit from preoperative coronary revascularization. The present article provides an extended overview of leading observational studies, randomized, controlled trials, meta-analyses and guidelines assessing perioperative β-blocker therapy and prophylactic coronary revascularization.

Keywords::

• acute coronary event
• angina pectoris
• asymptomatic ischemia
• β-blocker
• cardiac risk stratification
• major vascular surgery
• optimal medical treatment
• prophylactic revascularization

Financial & competing interests disclosure

Willem-Jan Flu, Jan-Peter van Kuijk, Tamara Winkel and Sanne Hoeks are supported by an unrestricted research grant from the ‘Lijf and Leven’ Foundation, Rotterdam, The Netherlands. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Notes

^*Clinical predictors of increased perioperative risk: major – unstable coronary syndromes, decompensated heart failure, significant arrhythmias and severe valvular disease; intermediate – mild angina pectoris, previous myocardial infarction, compensated or prior heart failure, diabetes mellitus and renal dysfunction; minor – advanced age, abnormal ECG, rhythm other than sinus, low functional capacity, history of stroke and uncontrolled systemic hypertension.

Data from [41].