Recent studies suggest that preoperative cardiac stress testing is unnecessary in low to intermediate cardiac risk patients undergoing operations, and that targeted beta blockade is cardiac protective.
A cohort study of patients undergoing vascular surgery or major amputation, with low to intermediate cardiac risk, but without cardiac stress testing, was performed. Targeted beta blockade was initiated preoperatively. The primary end point was a composite of adverse cardiac outcomes. A comparison was made with historical controls who received selective stress testing and selective nontargeted beta blockade.
One hundred consecutive patients were prospectively enrolled, and 80 retrospective controls were identified. There were no differences between groups with respect to median revised cardiac index (RCI; 0 versus 1). In the retrospective group, 14% underwent preoperative cardiac stress testing versus none in the prospective group (p = 0.0002). Nontargeted beta blockade was given in 61% of the retrospective group. The median heart rate for the prospective group was significantly lower (66 versus 77 beats/minute; p = 0.0007). The composite cardiac complication rate was 2% in the prospective group versus 10% in the retrospective group (p = 0.02). There were no deaths. On multivariate analysis, after adjusting for revised cardiac index score, there was a lower cardiac complication rate in the prospective group (odds ratio, 2.46; 95% CI, 1.3 to 4.5; p = 0.003).
In patients undergoing vascular surgery or major amputation, with low to intermediate cardiac risk, preoperative targeted beta blockade alone is more effective than selective cardiac stress testing and nontargeted beta blockade in preventing cardiac morbidity.