Timing of Pre-Operative Beta-Blocker Treatment in Vascular Surgery Patients

Objectives This study evaluated timing of beta-blocker initiation before surgery and its relationship with: 1) pre-operative heart rate and high-sensitivity C-reactive-protein (hs-CRP) levels; and 2) post-operative outcome. Background Perioperative guidelines recommend beta-blocker initiation days to weeks before surgery, on the basis of expert opinions. Methods In 940 vascular surgery patients, pre-operative heart rate and hs-CRP levels were recorded, next to timing of beta-blocker initiation before surgery (0 to 1, > 1 to 4, > 4 weeks). Pre- and post-operative troponin-T measurements and electrocardiograms were performed routinely. End points were 30-day cardiac events (composite of myocardial infarction and cardiac mortality) and long-term mortality. Multivariate regression analyses, adjusted for cardiac risk factors, evaluated the relation between duration of beta-blocker treatment and outcome. Results The beta-blockers were initiated 0 to 1, > 1 to 4, and > 4 weeks before surgery in 158 (17%), 393 (42%), and 389 (41%) patients, respectively. Median heart rate at baseline was 74 (+/- 17) beats/min, 70 (+/- 16) beats/min, and 66 (+/- 15) beats/min (p < 0.001; comparing treatment initiation > 1 with < 1 week pre-operatively), and hs-CRP was 4.9 (+/- 7.5) mg/l, 4.1 (+/-.6.0) mg/l, and 4.5 (+/- 6.3) mg/l (p = 0.782), respectively. Treatment initiated > 1 to 4 or > 4 weeks before surgery was associated with a lower incidence of 30-day cardiac events (odds ratio: 0.46, 95% confidence interval [CI]: 0.27 to 0.76, odds ratio: 0.48, 95% CI: 0.29 to 0.79) and long-term mortality (hazard ratio: 0.52, 95% CI: 0.21 to 0.67, hazard ratio: 0.50, 95% CI: 0.25 to 0.71) compared with treatment initiated < 1 week pre-operatively. Conclusions Our results indicate that beta-blocker treatment initiated > 1 week before surgery is associated with lower pre-operative heart rate and improved outcome, compared with treatment initiated < 1 week pre-operatively. No reduction of median hs-CRP levels was observed in patients receiving beta-blocker treatment > 1 week compared with patients in whom treatment was initiated between 0 and 1 week before surgery. (J Am Coll Cardiol 2010;56:1922-9) (C) 2010 by the American College of Cardiology Foundation