Chapter 25. Beta-blockers and Reduction of Perioperative Cardiac Events

As the most common complications of major noncardiac surgery, myocardial infarction and cardiovascular death have long been a focus of preoperative evaluations and a target of perioperative management strategies. Until recently, methods to reduce the incidence of these complications depended upon preoperative assessments of risk combining clinical evaluation with clinical prediction rules, followed by additional tests or revascularization procedures, as appropriate. The benefit of preoperative revascularization remains unclear, as no randomized prospective trial has demonstrated its benefit. Indeed, concern exists that preoperative intervention might prove detrimental, as the net benefit in terms of reduced perioperative cardiac events may be offset by the risks of the revascularization strategy itself. Newer strategies, including the use of percutaneous transluminal angioplasty as the revascularization modality, may have promise. Large prospective trials examining these approaches are underway. Strong evidence links myocardial ischemia with postoperative myocardial events. One study found postoperative ischemia increased the odds of postoperative myocardial events 21fold. Based on findings from observational studies that beta-blockade blunts electrocardiographic signs of ischemia, recent trials have examined the effects of perioperative beta-blocker administration on patient outcomes. Results of these investigations are extremely promising, and beta-blockade may represent an important new method of reducing perioperative cardiac risk. This chapter reviews the evidence from randomized controlled trials examining the effect of perioperative beta-blockade on cardiac events (ie, myocardial ischemia, angina, myocardial infarction, pulmonary edema, and cardiac death).