Pharmacologic modulation of operative risk in patients who have cardiac disease.
Cardiac complications continue to compose a major proportion of serious postoperative morbidity and mortality, and it is appropriate, therefore, that this area has received a lot of attention in the search for pharmacologic modulation of surgical outcomes. Despite numerous studies, conclusive data does not exist, making it difficult to recommend a course of action. beta-blockade has not only made it into national protocols, but is even considered as a quality assessment measure. However, the data are not quite as conclusive as it may sometimes appear. There have been few studies, with a small number of negative outcomes, and, at times, significant methodological concerns. The positive outcomes of meta-analyses rest essentially on a single trial in a highly selected patient population. Although use of beta-blockers in patients who have documented coronary artery disease and are undergoing major vascular procedures appears supported, it is premature to recommend beta-blockade for all patients with cardiac risk. Because these drugs are not without risks, it might be advisable to be restrained in their use until the results of the large-scale randomized POISE trial are available. For clonidine and statins, the data are even more tenuous, and largely based on retrospective reviews (with the exception of postprocedure use of statins, which is well supported). Here again, the results of large-scale prospective trials must become available before recommendations can be made. Finally, promising data indicate that it might be possible to modulate by pharmacologic means the neurocognitive decline that is frequently associated with cardiac surgery, and which is often considered by patients to be the most troublesome complication of the intervention.
Shilling
Ashley M
AM
Department of Anesthesia, University of Virginia Health System, Old Medical School, Room 4748, Charlottesville, VA 22908-0710, USA. abm5f@virginia.edu
Durieux
Marcel E
ME
D006348:Cardiac Surgical Procedures / Q000401:mortality; D003072:Cognition Disorders / Q000209:etiology / Q000517:prevention & control; D006331:Heart Diseases / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery; D006801:Humans; D007431:Intraoperative Complications / Q000401:mortality / Q000517:prevention & control; D017202:Myocardial Ischemia / Q000401:mortality / Q000517:prevention & control; D019990:Perioperative Care / Q000379:methods; D011183:Postoperative Complications / Q000401:mortality / Q000517:prevention & control*; D012307:Risk Factors; D013514:Surgical Procedures, Operative / Q000401:mortality