Timing of Pre-Operative Beta-Blocker Treatment in Vascular Surgery Patients

• Published in: Journal of the American College of Cardiology Vol. 56; no. 23; pp. 1922 - 1929
• Main Authors: Flu, Willem-Jan, MD, van Kuijk, Jan-Peter, MD, Chonchol, Michel, MD, Winkel, Tamara A., MD, Verhagen, Hence J.M., MD, Bax, Jeroen J., MD, Poldermans, Don, MD
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 30.11.2010
• Subjects: Cardiovascular; Internal Medicine; prognosis; vascular surgery; β-blocker therapy; renin-angiotensin-aldosterone system; β-blocker therapy; CI; myocardial infarction; RAAS; confidence interval; high-sensitivity C-reactive protein; MI; prognosis; vascular surgery; hs-CRP
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2010.05.056

Objectives This study evaluated timing of β-blocker initiation before surgery and its relationship with: 1) pre-operative heart rate and high-sensitivity C-reactive-protein (hs-CRP) levels; and 2) post-operative outcome. Background Perioperative guidelines recommend β-blocker initiation days to weeks before surgery, on the basis of expert opinions. Methods In 940 vascular surgery patients, pre-operative heart rate and hs-CRP levels were recorded, next to timing of β-blocker initiation before surgery (0 to 1, >1 to 4, >4 weeks). Pre- and post-operative troponin-T measurements and electrocardiograms were performed routinely. End points were 30-day cardiac events (composite of myocardial infarction and cardiac mortality) and long-term mortality. Multivariate regression analyses, adjusted for cardiac risk factors, evaluated the relation between duration of β-blocker treatment and outcome. Results The β-blockers were initiated 0 to 1, >1 to 4, and >4 weeks before surgery in 158 (17%), 393 (42%), and 389 (41%) patients, respectively. Median heart rate at baseline was 74 (±17) beats/min, 70 (±16) beats/min, and 66 (±15) beats/min (p < 0.001; comparing treatment initiation >1 with <1 week pre-operatively), and hs-CRP was 4.9 (±7.5) mg/l, 4.1 (±.6.0) mg/l, and 4.5 (±6.3) mg/l (p = 0.782), respectively. Treatment initiated >1 to 4 or >4 weeks before surgery was associated with a lower incidence of 30-day cardiac events (odds ratio: 0.46, 95% confidence interval [CI]: 0.27 to 0.76, odds ratio: 0.48, 95% CI: 0.29 to 0.79) and long-term mortality (hazard ratio: 0.52, 95% CI: 0.21 to 0.67, hazard ratio: 0.50, 95% CI: 0.25 to 0.71) compared with treatment initiated <1 week pre-operatively. Conclusions Our results indicate that β-blocker treatment initiated >1 week before surgery is associated with lower pre-operative heart rate and improved outcome, compared with treatment initiated <1 week pre-operatively. No reduction of median hs-CRP levels was observed in patients receiving β-blocker treatment >1 week compared with patients in whom treatment was initiated between 0 and 1 week before surgery.