Beta blockade aids in oncardiac surgery
Prophylaxis reduces cardiovascular risk
One month of atenolol treatment costs about $30 clearly less than a readmit for acute myocardial infarction (AMI) or angina. It follows that controlling cardiovascular risk factors in the period before, during, and after noncardiac surgeries can result in cost savings. Aspirin, beta blockers, and angiotensin converting enzyme (ACE) inhibitors are all part of that protocol. A recent study shows that in patients with or at risk for coronary artery disease (CAD) who undergo noncardiac surgery, perioperative treatment with the beta-blocker atenolol reduces mortality by 50% and keeps cardiovascular complications at bay for as long as two years.1
"It makes good cost-effective sense," says Stephen Winbery, MD, PhD, principal clinical coordinator at the Mid-South Foundation for Medical Care in Memphis, TN. "[Using] a beta blocker like atenolol prevents cardiac complications, especially during the fight or flight’ stress of surgery."
The pre-surgery evaluation
Perioperative myocardial ischemia is the single most important and potentially reversible risk factor following noncardiac surgery. Even for patients at high risk, outcome is likely to be favorable as long as proper cardiovascular care is instituted. Your first opportunity to make that happen is during a thorough presurgery evaluation. Patients with clear evidence of coronary disease should receive aggressive therapy for elevated serum lipid concentrations and daily aspirin except where contraindicated. In addition, appropriately administered beta blockers and ACE inhibitors can reduce risk. Preoperative stress testing is not typically recommended.
Without question, the following two groups should receive perioperative beta blockade:
• patients already taking beta blockers;
• patients with clear or likely evidence of underlying coronary heart disease, particularly if there’s concomitant hypertension.
A New England Journal of Medicine editorial accompanying the study on atenolol questioned the efficacy of treating patients who have cardiac risk factors but no underlying CAD.2 The bottom line is that administering the agents must be done on a case-by-case basis. Nitrates and calcium-channel blockers should be reserved for patients who require such medications to control ischemic symptoms.
Like a school bus governor
Beta blockers are lifesavers, and unless there’s a life-or-death reason not to administer the agents, they should be given. Not using perioperative atenolol may be keeping your program from reaching its maximum efficiency and cost effectiveness. Perioperative beta blockade likely improves outcomes by preventing catecholamine-mediated alterations in coronary vessels coronary-plaque fissuring or rupture that render patients susceptible to complications in the short term. Long-term protection is not so sure.
"Beta-blockers act like governors on the old school buses," says Winbery. "The governors allowed the buses to run, but they limited their speed and stopped them before they broke down. Similarly, beta-blockers are internal governors; they protect the heart by allowing only safe activity that doesn’t put the heart at risk."
The national Cooperative Cardiac Project administered by the Health Care Financing Administration (HCFA) in Baltimore continues to show that, in the AMI setting, beta-blocker usage is only 45% to 50% in this country. In European countries such as Switzerland, those numbers approach 80%. Thomas Marciniak, MD, national director of the project, has said that for every few percentage points beta-blocker prescribing goes up in this country, thousands of lives could be saved.
Cost Management in Cardiac Care asked Winbery why he thinks beta-blockers are underused. "Physician bias," he says. "In medical school we’re taught that beta-blockers are valuable, but we’re also taught that they shouldn’t be used in a number of conditions, such as depression, chronic obstructive pulmonary disease, asthma, and a long list of others. So doctors typically remember that beta-blockers are complicated, and sometimes it seems more expeditious to simply not prescribe them."
References
1. Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 1996; 335:1,713-1,720.
2. Eagle KA, Froehlich JB. Reducing cardiovascular risk in patients undergoing noncardiac surgery (editorial). N Engl J Med 1996; 335:1,761-1,762.
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