Transcript Cardioprotective Agents in the Total Joint Arthroplasty

Cardioprotective Agents
in the Total Joint
Arthroplasty Patient: Are
We Doing Enough?
Eric Schwenk MD*, Kishor Gandhi MD MPH*, Javad Parvizi MD^,
Eugene Viscusi MD*
*Department of Anesthesiology,
Thomas Jefferson University Hospital
^Rothman Institute for Orthopedics,
Thomas Jefferson University Hospital
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Introduction
For patients undergoing noncardiac surgery, cardiovascular
complications represent one of the biggest risks in the perioperative
period.
The Revised Cardiac Risk Index (RCRI) is a simple way to assess
cardiac risk for patients undergoing noncardiac surgery. 1
RCRI Predictors of Cardiovascular Complications
 High Risk Surgery
1 point
 Coronary Artery Disease
1 point
 Congestive Heart Failure
1 point
 Cerebrovascular Disease
1 point
 DM on Insulin
1 point
 Serum Cr > 2.0 mg/dl
1 point
The risk of major cardiac events during the perioperative period as
predicted by RCRI:
 No point = Low risk (0.4% complications)
 1 point = Low risk (0.9% complications)
 2 point = Intermediate risk (6.6% complications)
 More than 2 points = High risk (11.0% complications)
1. Lee TH et al. Circulation 1999;100:1043.
Introduction
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The use of cardioprotective agents for the prevention of CV
complications in noncardiac surgery is controversial, particularly
with beta blockers.
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The 2006 ACC/AHA guidelines update on perioperative beta
blocker use described major limitations in prior studies, including
inadequate power, lack of titration to a target heart rate, omission
of low- and intermediate-risk patients, and lack of evidence on
which beta blocker to choose.2
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The POISE trial, a large, prospective, randomized controlled
trial, addressed some of these concerns and found that beta
blockers reduced the risk of postop MI but increased the risk of
stroke and overall mortality. However, BBs were not titrated to
a target heart rate and, in addition, a high dose of the BB was
given. This could account for some of the strokes that were
observed.3
Introduction
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The risk of perioperative myocardial ischemia during noncardiac
vascular surgery is reduced in patients whose heart rates are
tightly controlled (HR < 65 bpm).4
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A 2008 meta-analysis suggested that beta blockers are
cardioprotective if the patients’ maximal heart rate is <100 bpm.
It also found that calcium channel blockers combined with beta
blockers result in more effective control of heart rate.5
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Short-term statin use has been shown to reduce cardiac events in
patients undergoing vascular surgery.6 They may also be
cardioprotective in other noncardiac surgeries.7
Poldermans D et al. J Am Coll Cardiol 2006;48(5):964-9. 5 Beattie WS et al. Anes Analg 2008;106(4):1039-48. 6 Durazzo AE et al.
J Vasc Surg 2004;39(5):967-75. 7 Lindenauer PK et al. JAMA 2004; 291(17):2092-9.
Objectives
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To assess the percentage of total joint
arthroplasty patients experiencing postop CV
complications who took preoperative beta
blockers, calcium channel blockers, and statins.
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To determine if beta blockers and calcium
channel blockers are being titrated to a target
heart rate.
Methods
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Retrospective cohort study of 3529 patients who underwent total
joint arthroplasty (hip or knee replacement) at a large, urban
teaching hospital.
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Postoperative complications were recorded into a database by a
team of researchers and linked to a database containing patients’
past medical history, medication history, preoperative
medications, and preoperative vital signs.
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Postoperative cardiovascular complications were defined as:
angina, myocardial infarction, atrial fibrillation, tachycardia,
supraventricular
tachycardia,
miscellaneous
arrythmias,
pulmonary edema, acute congestive heart failure, hypotension,
and bradycardia.
Results
Table 1: Postoperative Cardiovascular Complications by Risk
Stratification
Cardiovascular
Complications (n=188)
Low Risk
(n=129,
68.6%)
Intermediate Risk
(n=56, 29.8%)
Age>60 (n=131)
84 (64.1%)* 44 (33.6%)*
3 (2.3%)
Angina/MI (n=49)
23 (46.9%)* 25 (51.0%)*
1 (2.0%)
Tachycardia/Arrhythmias
(n=65)
47 (72.3%)
17 (26.2%)
1 (1.5%)
Pulmonary Edema/CHF
(n=14)
8 (57.10%)
5 (35.7%)
1 (7.10%)
Hypotension (n=47)
40 (85.1%)* 7 (14.9%)*
0 (0%)
Bradycardia (n=13)
N (%)
* p<0.05
11 (84.6%)
0 (0%)
2 (15.40%)
High Risk
(n=3, 1.6%)
Results
Figure 1: Preoperative Cardioprotective Agents
Results
Table 2: Tight Rate Control (<65 bpm)
Rate Control Agent
None
Long-term BB
BB on day of surgery
Long-term CCB
CCB on day of surgery
Long-term BB and CCB
BB and CCB on day of
surgery
Percentage of Patients
with Tight Rate Control
32.0% (n=58)
33.3% (n=19)
32.1% (n=18)
45.7% (n=16)
37.5% (n=12)
40.0% (n=2)
33.3% (n=3)
Results
Figure 2: Tight Rate Control by Complication
Discussion
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The majority of patients who experienced
cardiovascular complications were not taking beta
blockers, calcium channel blockers, or statins before
surgery. Most of these patients were low- or
intermediate-risk, emphasizing the importance of
including these patients in future studies.
Our results suggest that adequate rate control is not
being achieved in the majority of patients taking beta
blockers or calcium channel blockers before total joint
arthroplasty. Combining the two agents might lead to
better rate control, but a prospective trial is needed to
confirm this.
Discussion
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For patients in whom a beta blocker or calcium channel
blocker is deemed appropriate, adequate rate control
may need to be achieved by more aggressive
titration in the perioperative period, combining
the agents as appropriate to avoid bradycardia
and hypotension.
The use of short-term statins in noncardiac
surgery may be cardioprotective8,9 and some of
the patients who experienced cardiovascular
complications may benefit from a statin.
8. Durazzo AE et al. J Vasc Surg 2004;39(5):967-75
9. Lindenauer PK et al. JAMA 2004; 291(17):2092-9.
Thank You
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Dr. Kishor Gandhi – Regional Anesthesia Fellow; St.
Luke’s Hospital, New York, NY
Dr. Eugene Viscusi – Director, Acute Pain Management
Service; Thomas Jefferson University Hospital,
Philadelphia, PA
Dr. Zvi Grunwald – Chair, Department of
Anesthesiology; Thomas Jefferson University Hospital,
Philadelphia, PA