Should Major Vascular Surgery Be Delayed Because of Preoperative Cardiac Testing in Intermediate-Risk Patients Receiving Beta-Blocker Therapy With Tight Heart Rate Control?

Should Major Vascular Surgery Be Delayed Because of Preoperative Cardiac Testing in Intermediate-Risk Patients Receiving Beta-Blocker Therapy With Tight Heart Rate Control? Don Poldermans, Jeroen J. Bax, Olaf Schouten, Aleksandar N. Neskovic, Bernard Paelinck, Guido Rocci, Laura van Dortmont, Anai E.S. Durazzo, Louis L.M. van de Ven, Marc R.H.M. van Sambeek, Miklos D. Kertai, Eric Boersma, for the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo Study Group Treatment guidelines of the American College of Cardiology/American Heart Association recommend cardiac testing in intermediate-risk patients before major vascular surgery. This policy delays surgery, although test results might be redundant and beta-blockers with tight heart rate control provide sufficient myocardial protection. In total, 1,476 patients were screened and stratified into low-risk, intermediate-risk, and high-risk. The 770 intermediate-risk patients were randomly assigned to cardiac stress-testing (n = 386) or no-testing. Patients assigned to no-testing had similar incidence of cardiac death or myocardial infarction at 30-days after surgery as those assigned to testing (1.8% vs. 2.3%; odds ratio 0.78; 95% confidence interval 0.28 to 2.1; p = 0.62). 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. 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. All 1,476 screened patients were stratified into low-risk (0 risk factors), intermediate-risk (1 to 2 risk factors), and high-risk (≥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. Testing showed no ischem