Conference Coverage
Neither perioperative aspirin nor clonidine prevents MI
Major finding: The primary outcome of death or MI occurred in 7% of the aspirin group and 7.1% of the placebo group, a nonsignificant difference;...
A new clinical practice guideline on cardiovascular evaluation and management of patients undergoing noncardiac surgery adds some clarity around the controversial issue of beta-blocker therapy and updates other aspects of care.
If a patient on beta-blocker medication needs noncardiac surgery, continue the beta-blocker, because there is no evidence of harm from doing so; but you risk doing harm if the drug is stopped, according to the new guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA).
Dr. Lee A. Fleisher
Surgeons will be happy to hear that, said Dr. Lee A. Fleisher, the chair of the guideline-writing committee, because that conforms to one of the Surgical Care Improvement Project’s National Measures.
For patients at elevated risk of a cardiovascular event during noncardiac surgery who are not already on beta-blocker therapy, however, the new guideline steps back from the organization’s 2009 position that beta-blockers not be started, and says instead that it’s not unreasonable to start the drug, with a caveat. Be very cautious and start the drug early enough before surgery that you can titrate it to avoid causing hypotension or a low heart rate.
"Make sure that you’re giving the right amount and monitoring their blood pressure and heart rate," Dr. Fleisher, chair of the guideline writing committee, said in an interview. "Really think once, twice, and thrice about starting a protocol," added Dr. Fleisher, the Robert D. Dripps Professor of Anesthesiology and Critical Care at the University of Pennsylvania, Philadelphia.
The ACC and AHA commissioned a committee to review the evidence for and against beta-blockers in patients undergoing noncardiac surgery. A separate writing committee then considered the evidence review committee’s report, reviewed the literature on other aspects of perioperative care for noncardiac surgery, and compiled a 102-page guideline with a 59-page executive summary.
The "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" will be published online on the ACC and AHA websites.
Dr. Fleisher described other highlights of the new guideline pertinent to cardiologists, primary care physicians, or surgeons. For the first time, palliative care has been added as an option that may come out of the preoperative evaluation, he said. Patient categories of high risk and intermediate risk have been lumped together as having "elevated" risk for simplicity’s sake because recommendations for the two separate categories were so similar.
The guideline now endorses two tools to choose from for preoperative risk assessments: the Revised Cardiac Risk Index (RCRI), and the National Surgical Quality Improvement Project risk calculator. "There have been a lot of comments that [the NSQIP] is a very useful tool to have shared decision-making conversations with patients," he said.
Another change applies to patients who receive second- or third-generation coronary stents. Instead of a wait of a year after stent implantation to perform noncardiac surgery, a 6-month wait may be reasonable if the risks of delaying noncardiac surgery outweigh the risks of interrupting dual-antiplatelet therapy for the noncardiac surgery.
In addition, the guideline incorporates findings from the recent POISE-2 study to say that aspirin can be stopped and clonidine is not useful in patients without stents undergoing noncardiac surgery (N. Engl. J. Med. 2014;370:1494-503).
A new statement in the guideline about troponin says to check troponin in high-risk patients with signs or symptoms of trouble but not to include troponin in routine screening.
The recommendations on beta-blockers, however, address the most controversial topic in the guideline, Dr. Fleisher said. "There is a lot of confusing evidence" on the use of beta-blockers, "so we’ve tried to clarify as much as we can."
The ACC and AHA funded the work of the committees. Dr. Fleisher reported having no financial disclosures.
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