Ida M. Tateo

Effect of Atenolol on Mortality and Cardiovascular Morbidity after Noncardiac Surgery

BACKGROUND Perioperative myocardial ischemia is the single most important potentially reversible risk factor for mortality and cardiovascular complications after noncardiac surgery. Although more than 1 million patients have such complications annually, there is no effective preventive therapy. METHODS We performed a randomized, double-blind, placebo-controlled trial to compare the effect of atenolol with that of a placebo on overall survival and cardiovascular morbidity in patients with or at risk for coronary artery disease who were undergoing noncardiac surgery. Atenolol was given intravenously before and immediately after surgery and orally thereafter for the duration of hospitalization. Patients were followed over the subsequent two years. RESULTS A total of 200 patients were enrolled. Ninety-nine were assigned to the atenolol group, and 101 to the placebo group. One hundred ninety-four patients survived to be discharged from the hospital, and 192 of these were followed for two years. Overall mortality after discharge from the hospital was significantly lower among the atenolol-treated patients than among those who were given placebo over the six months following hospital discharge (0 vs. 8 percent, P<0.001), over the first year (3 percent vs. 14 percent, P=0.005), and over two years (10 percent vs. 21 percent, P=0.019). The principal effect was a reduction in deaths from cardiac causes during the first six to eight months. Combined cardiovascular outcomes were similarly reduced among the atenolol-treated patients; event-free survival throughout the two-year study period was 68 percent in the placebo group and 83 percent in the atenolol group (P=0.008). CONCLUSIONS In patients who have or are at risk for coronary artery disease who must undergo noncardiac surgery, treatment with atenolol during hospitalization can reduce mortality and the incidence of cardiovascular complications for as long as two years after surgery.

Association of Perioperative Myocardial Ischemia with Cardiac Morbidity and Mortality in Men Undergoing Noncardiac Surgery

BACKGROUND Adverse cardiac events are a major cause of morbidity and mortality after noncardiac surgery. It is necessary to determine the predictors of these outcomes in order to focus efforts on prevention and treatment. Patients undergoing noncardiac surgery sometimes have postoperative cardiac events. It would be helpful to know which patients are at highest risk. METHODS We prospectively studied 474 men with coronary artery disease (243) or at high risk for it (231) who were undergoing elective noncardiac surgery. We gathered historical, clinical, laboratory, and physiologic data during hospitalization and for 6 to 24 months after surgery. Myocardial ischemia was assessed by continuous electrocardiographic monitoring, beginning two days before surgery and continuing for two days after. RESULTS Eighty-three patients (18 percent) had postoperative cardiac events in the hospital that were classified as ischemic events (cardiac death, myocardial infarction, or unstable angina) (15 patients), congestive heart failure (30), or ventricular tachycardia (38). Postoperative myocardial ischemia occurred in 41 percent of the monitored patients and was associated with a 2.8-fold increase in the odds of all adverse cardiac outcomes (95 percent confidence interval, 1.6 to 4.9; P less than 0.0002) and a 9.2-fold increase in the odds of an ischemic event (95 percent confidence interval, 2.0 to 42.0; P less than 0.004). Multivariate analysis showed no other clinical, historical, or perioperative variable to be independently associated with ischemic events, including cardiac-risk index, a history of previous myocardial infarction or congestive heart failure, or the occurrence of ischemia before or during surgery. CONCLUSIONS In high-risk patients undergoing noncardiac surgery, early postoperative myocardial ischemia is an important correlate of adverse cardiac outcomes.

Prophylactic atenolol reduces postoperative myocardial ischemia

Background Perioperative myocardial ischemia occurs in 20–40% of patients at risk for cardiac complications and is associated with a ninefold increase in risk for perioperative cardiac death, myocardial infarction, or unstable angina, and a twofold long‐term risk. Perioperative atenolol administration reduces the risk of death for as long as 2 yr after surgery. This randomized, placebo‐controlled, double‐blinded trial tested the hypothesis that perioperative atenolol administration reduces the incidence and severity of perioperative myocardial ischemia, potentially explaining the observed reduction in the risk for death. Methods Two‐hundred patients with, or at risk for, coronary artery disease were randomized to two study groups (atenolol and placebo). Monitoring included a preoperative history and physical examination and daily assessment of any adverse events. Twelve‐lead electrocardiography (ECG), three‐lead Holter ECG, and creatinine phosphokinase with myocardial banding (CPK with MB) data were collected 24 h before until 7 days after surgery. Atenolol (0, 5, or 10 mg) or placebo was administered intravenously before induction of anesthesia and every 12 h after operation until the patient could take oral medications. Atenolol (0, 50, or 100 mg) was administered orally once a day as specified by blood pressure and heart rate. Results During the postoperative period, the incidence of myocardial ischemia was significantly reduced in the atenolol group: days 0–2 (atenolol, 17 of 99 patients; placebo, 34 of 101 patients; P = 0.008) and days 0–7 (atenolol, 24 of 99 patients; placebo, 39 of 101 patients; P = 0.029). Patients with episodes of myocardial ischemia were more likely to die in the next 2 yr (P = 0.025). Conclusions Perioperative administration of atenolol for 1 week to patients at high risk for coronary artery disease significantly reduces the incidence of postoperative myocardial ischemia. Reductions in perioperative myocardial ischemia are associated with reductions in the risk for death at 2 yr.

Differences Between Primary Care Physicians and Cardiologists in Management of Congestive Heart Failure: Relation to Practice Guidelines

OBJECTIVES This study was designed to characterize physician practices in the management of congestive heart failure (CHF) and to determine whether these practices vary by specialty and how they relate to guideline recommendations. BACKGROUND Congestive heart failure is responsible for considerable mortality, morbidity and health care resource utilization. Although there have been important advances in the diagnostic evaluation and treatment of CHF, little information is available on physician practices in this area. METHODS We surveyed physicians concerning their management of patients with CHF. The results were analyzed in multivariate models to determine the relation of diagnostic and treatment approaches to physician specialty, time since training, board certification and volume of patients with CHF. Surveys were sent to a sample of 2,250 family and general practitioners (FP/GPs), internists and cardiologists. Responses were examined in relation to guidelines issued by the Agency for Health Care Policy and Research that had been released 9 months previously. RESULTS Significant differences were found between physician groups with regard to each of the major guideline recommendations. For example, routine evaluation of left ventricular function, a point of emphasis in the guideline, is performed by 87% of cardiologists, but by only 77% of internists and 63% of FP/GPs (p < 0.001 between groups). Angiotensin-converting enzyme inhibitors were used by cardiologists, internists and FP/GPs in 80%, 71% and 60% of patients with mild to moderate CHF, respectively (p < 0.001 between groups). Larger differences were reported in the prescribed dosages of these drugs and their use in patients with renal dysfunction. CONCLUSIONS Cardiologists report practices more in conformity with published guidelines for CHF than do internists and FP/GPs. Because of the large numbers of patients with CHF and their substantial mortality, morbidity and cost of care, these differences may have a major impact on outcomes and health care costs.

Echocardiography for assessing cardiac risk in patients having noncardiac surgery

Cardiac complications developing after noncardiac surgery are often serious, sometimes fatal, and almost always costly. An estimated 9 million of the 28 million patients in the United States who have noncardiac surgery each year are thought to have a high risk for postoperative cardiac complications because they are known to have or are suspected of having ischemic heart disease [1, 2]. As a result of this risk, approximately 1.5 million persons have adverse cardiac events each year, at a cost of more than

Self-reported differences between cardiologists and heart failure specialists in the management of chronic heart failure.

20 billion annually [1]. Cardiac assessment before elective surgery relies on two strategies: assessment of risk factors and diagnostic testing. Assessing risk factors involves ascertaining clinical characteristics that are associated with such cardiac complications as previous myocardial infarction, congestive heart failure, dysrhythmias, vascular disease, hypertension, diabetes mellitus, advanced age, and renal dysfunction [3-5]. However, many authorities advocate the use of noninvasive diagnostic tests to more precisely identify patients who are at high risk for perioperative illness and death [6]. The value of dipyridamidole-thallium scintigraphy has been widely studied but remains controversial [7-11]. Similarly, the use of radionuclide assessment of left ventricular function has been correlated with postoperative cardiac events in some studies [12, 13] but not in others [11, 14, 15]. Because of these controversies and the high costs of these tests, other, less-expensive approaches are being investigated. One commonly used test, transthoracic echocardiography, is increasingly used before surgery to assess cardiac risk because it provides information on global and regional ventricular function [16, 17]. Echocardiography is readily available; costs less than dipyridamidole-thallium scintigraphy and radionuclide angiography; and involves no intravenous injections, isotope handling, or exposure to radiation. However, its prognostic value in assessing cardiac risk before surgery is not known. We examined the usefulness of transthoracic echocardiography by posing two questions: 1) Can information from an echocardiogram routinely obtained before noncardiac surgery identify patients at risk for adverse cardiac outcomes after surgery? and 2) Do the echocardiographic data add any incremental prognostic information to the information already available from the history, physical examination, electrocardiogram, and laboratory studies? To answer these questions, we studied a cohort of patients who were known to have or were suspected of having ischemic heart disease, were scheduled for elective noncardiac surgery, and had preoperative echocardiography as part of the Study of Perioperative Ischemia. Methods Patients The study sample was drawn from a prospective cohort of 474 male veterans who were scheduled to have elective noncardiac surgery that required general anesthesia at the San Francisco Veterans Affairs Medical Center as part of the study of Perioperative Ischemia [4]. These men had definite coronary artery disease or a high risk for developing this disease. Consecutive patients who met entry criteria were enrolled from January 1987 to September 1989. The Committee on Human Research approved the study protocol, and all patients gave informed consent. Patients were considered to have definite coronary artery disease if they had previously had myocardial infarction, had typical angina, or had atypical angina with evidence of inducible ischemia shown by exercise testing [18] or evidence of myocardial perfusion defects shown by scintigraphy [19]. Patients were classified as having a high risk for coronary artery disease if they had previously had or were scheduled to have vascular surgery or if they had two or more of the following cardiac risk factors (in addition to male sex): diabetes mellitus, hypertension, age of 65 years or greater, current smoking, or a serum cholesterol level of at least 6.2 mmol/L (240 mg/dL). We excluded patients with paced rhythms or complete left bundle-branch block. Echocardiography was successfully done before surgery in 368 patients (78%). Echocardiograms were unavailable for the other patients because of scheduling problems, technical failures, or inadequate examinations. Our cohort comprised the 339 patients (92%) whose echocardiograms could be interpreted. Data Collection and Measurement A study physician did a routine clinical evaluation and reviewed the medical record of each patient before surgery. Clinical variables of interest were information from the history, physical examination, electrocardiography, and laboratory studies. All cardiovascular medications were recorded. The Canadian Cardiovascular Society classification of angina [20], the New York Heart Association classification of heart failure [21], the Goldman cardiac risk index [3], the Detsky risk index [5], and the American Society of Anesthesiologists classification of anesthetic risk [22] were also determined for each patient. Surgery was classified as major vascular (108 patients), intra-abdominal (76 patients), intrathoracic (21 patients), and other (134 patients; this category consisted of orthopedic, neurosurgical, general, plastic, and head and neck procedures). Preoperative testing included routine laboratory studies and 12-lead electrocardiography. The 12-lead electrocardiogram was analyzed for evidence of previous myocardial infarction using the Minnesota Code criteria [23] and was analyzed for left ventricular hypertrophy using the Sokolow-Lyon [24] and Romhilt-Estes [25] criteria. Standard two-dimensional and M-mode echocardiography were done in each patient before surgery. Standard parasternal long- and short-axis views, apical two- and four-chamber views, and subxiphoid views were obtained. A General Electric Pass II machine (Milwaukee, Wisconsin) equipped with 2.5- and 3.5-MHz transducer probes was used. Videotapes of the echocardiograms were read by one of two research cardiologists who were blinded to the clinical history, research data, and outcome events. The variability with which echocardiograms are interpreted in our laboratory has been reported previously; the interobserver, intraobserver, and interexamination agreement rates all exceed 90% [26]. Echocardiographic variables of interest were left ventricular systolic ejection fraction, regional wall motion abnormalities, and the presence of left ventricular hypertrophy. Ejection fraction was assessed visually, and numeric estimates were assigned when the endocardial resolution of both short-axis and four-chamber views or four- and two-chamber views was adequate. Left ventricular wall motion was assessed using standard techniques [26]. We used a standard system to assign wall motion scores for the anterobasal, anterolateral, apical, posterobasal, and diaphragmatic walls. Each segment was graded as 1 (normal wall motion), 2 (mild hypokinesis), 3 (severe hypokinesis), 4 (akinesis), or 5 (dyskinesis). The total wall motion score was calculated as the sum of the regional wall motion scores (range, 5 to 25). Left ventricular hypertrophy, determined by measuring wall thickness in the parasternal views, was deemed to be present if either the septal or the posterior wall was at least 11 mm thick. Clinical Care and Outcomes Research data were collected by independent study physicians in conjunction with routine clinical care. Patients were interviewed and examined by a study physician before surgery and then daily from the day of surgery until hospital discharge. Physicians directly involved in patient care were blinded to the research data, including the echocardiographic information. A 12-lead electrocardiogram was obtained before surgery, each day for the first 7 days after surgery, on days 10 and 14 after surgery, at hospital discharge, and when clinically indicated. Serum cardiac enzyme levels were measured before surgery, on days 1 and 5 after surgery, and when clinically indicated by symptoms or electrocardiographic changes [4]. Clinicians had full independence in medical decision making. Perioperative cardiac outcomes were documented by study physicians and were validated by two independent investigators who were blinded to the clinical and echocardiographic data obtained before surgery. The following adverse cardiac outcomes were considered hierarchically, in descending order of severity: cardiac-related death, nonfatal myocardial infarction, unstable angina, congestive heart failure, and ventricular tachycardia. If a patient had several outcomes, we considered only the most severe event. Cardiac-related death, nonfatal myocardial infarction, and unstable angina were classified as ischemic events. Cardiac-related death was defined as death caused by myocardial infarction, dysrhythmia, or congestive heart failure. Diagnosis of myocardial infarction required an elevation of the creatine-kinase MB isoenzyme level ( 0.83 mol/L per second, equivalent to 50 U/L) and at least one of the following: development of new Q waves (as defined by Minnesota Code I.1 or I.2 [23]); development of persistent ST-T wave changes (as defined by Minnesota Code IV or V [23]); or evidence of acute infarction on necropsy. Unstable angina was defined as severe precordial chest pain that was not related to the surgical incision, lasted 30 minutes or longer, did not respond to standard therapies (rest and nitroglycerin), and was associated with transient ST-segment and T-wave changes without the development of Q waves or elevated enzyme levels. Diagnosis of congestive heart failure required 1) symptoms or signs of pulmonary edema [shortness of breath and rales]; 2) signs of new left or right ventricular failure [cardiomegaly, a third heart sound, jugular venous distention, and peripheral edema]; 3) abnormal results on chest radiography [vascular redistribution and interstitial or alveolar edema]; and 4) a change in medication that involved at least treatment with diureti

Long-term cardiac prognosis following noncardiac surgery

BACKGROUND Heart failure (HF) is responsible for considerable mortality morbidity rates and resource utilization. Recently, several studies have reported improved outcomes when patients are managed by special HF clinics, but it is uncertain whether this improvement reflects differences in physician practices or other aspects of the operation of these clinics. OBJECTIVES This study was designed to identify differences in HF management practices between general cardiologists and cardiologists specializing in the treatment of patients with HF. METHODS A survey examining diagnostic and treatment practices in patients with HF was sent to a sample of cardiologists derived from the American Medical Association Masterfile and to HF specialists who were members of the Society of Transplant Cardiologists or principal investigators in HF trials. Responses were examined in relation to guidelines issued by the Agency for Health care Policy and Research released 9 months previously. RESULTS In general both groups practice in conformity with published guidelines. However, there were important differences between the practice patterns of general cardiologists and HF specialists. For instance, in patients being evaluated for the first time, cardiologists reported using a chest radiograph to assist in the diagnosis more than did HF specialists (47% vs 12%), whereas HF specialists were more likely to use an echocardiogram (73% vs 48%). Both groups were likely to evaluate their patients for ischemia and possible revascularization, even in patients not having angina. However, HF specialists tended to use coronary angiography as the initial diagnostic test, whereas cardiologists were more likely to use stress testing. HF specialists more often used angiotensin-converting enzyme inhibitors as part of their initial therapy in patients with mild to moderate HF (94% vs 86%) and during maintenance therapy (91% vs 80%). Also, HF specialists were more likely than cardiologists to titrate angiotensin-converting enzyme inhibitors to higher doses (75% vs 35%), even in the presence of renal dysfunction. CONCLUSION Cardiologists and HF specialists generally manage their patients in conformity with guidelines. However, in many areas, such as angiotensin-converting enzyme inhibitor use, HF specialists do so more aggressively. These approaches may, in part, explain the success of the HF clinic model and raise the possibility that some portion of the HF population may be more optimally managed by cardiologists with a special interest in and additional training or experience with this condition.