title: Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control?
abstract: OBJECTIVE
  The purpose of this study was to assess the value of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate (HR) control scheduled for major vascular surgery.
  
  
  BACKGROUND
  Treatment guidelines of the American College of Cardiology/American Heart Association recommend cardiac testing in these patients to identify subjects at increased risk. This policy delays surgery, even though test results might be redundant and beta-blockers with tight HR control provide sufficient myocardial protection. Furthermore, the benefit of revascularization in high-risk patients is ill-defined.
  
  
  METHODS
  All 1,476 screened patients were stratified into low-risk (0 risk factors), intermediate-risk (1 to 2 risk factors), and high-risk (> or =3 risk factors). All patients received beta-blockers. The 770 intermediate-risk patients were randomly assigned to cardiac stress-testing (n = 386) or no testing. Test results influenced management. In patients with ischemia, physicians aimed to control HR below the ischemic threshold. Those with extensive stress-induced ischemia were considered for revascularization. The primary end point was cardiac death or myocardial infarction at 30-days after surgery.
  
  
  RESULTS
  Testing showed no ischemia in 287 patients (74%); limited ischemia in 65 patients (17%), and extensive ischemia in 34 patients (8.8%). Of 34 patients with extensive ischemia, revascularization before surgery was feasible in 12 patients (35%). Patients assigned to no testing had similar incidence of the primary end point as those assigned to testing (1.8% vs. 2.3%; odds ratio [OR] 0.78; 95% confidence interval [CI] 0.28 to 2.1; p = 0.62). The strategy of no testing brought surgery almost 3 weeks forward. Regardless of allocated strategy, patients with a HR <65 beats/min had lower risk than the remaining patients (1.3% vs. 5.2%; OR 0.24; 95% CI 0.09 to 0.66; p = 0.003).
  
  
  CONCLUSIONS
  Cardiac testing can safely be omitted in intermediate-risk patients, provided that beta-blockers aiming at tight HR control are prescribed.
authors.affiliation: Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands. d.poldermans@erasmusmc.nl
authors.forename: Don
authors.initials: D
authors.lastname: Poldermans
authors.forename: Jeroen J
authors.initials: JJ
authors.lastname: Bax
authors.forename: Olaf
authors.initials: O
authors.lastname: Schouten
authors.forename: Aleksandar N
authors.initials: AN
authors.lastname: Neskovic
authors.forename: Bernard
authors.initials: B
authors.lastname: Paelinck
authors.forename: Guido
authors.initials: G
authors.lastname: Rocci
authors.forename: Laura
authors.initials: L
authors.lastname: van Dortmont
authors.forename: Anai E S
authors.initials: AE
authors.lastname: Durazzo
authors.forename: Louis L M
authors.initials: LL
authors.lastname: van de Ven
authors.forename: Marc R H M
authors.initials: MR
authors.lastname: van Sambeek
authors.forename: Miklos D
authors.initials: MD
authors.lastname: Kertai
authors.forename: Eric
authors.initials: E
authors.lastname: Boersma
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D003324:Coronary Artery Disease / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D005080:Exercise Test; D005260:Female; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000517:prevention & control; D017202:Myocardial Ischemia; D010347:Patient Care Planning; D011300:Preoperative Care; D011379:Prognosis; D018570:Risk Assessment; D013997:Time Factors
chemical_list: D000319:Adrenergic beta-Antagonists