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Biomedical subjects

Don Poldermans

Publications and source records attributed to Don Poldermans.

At least 109 records · Page 6Linked to original sources
PubMed2004

Comparison of functional recovery of mildly hypokinetic versus severely dysfunctional left ventricular segments after revascularization in patients with ischemic cardiomyopathy.

Dysfunctional left ventricular (LV) segments showing contractile reserve during dobutamine stress echocardiography (DSE) are considered viable myocardium; functional recovery is expected after revascularization. Many segments, however, particularly mildly hypokinetic segments, do not recover. The reason for this failure is unknown. Two-dimensional echocardiography at rest and low-high-dose DSE were performed before revascularization in 114 consecutive patients with ischemic cardiomyopathy. Two-dimensional echocardiography at rest was repeated after 9 to 12 months. Segmental function was scored by a 5-point grading score. Functional recovery after revascularization was assessed in mildly hypokinetic (score 2, group I) and severely dysfunctional segments (score 3 to 5, group II). For each segment, functional recovery was defined as an improvement in functional score of > or =1 grade compared with the baseline score at rest. During low-dose DSE (up to 10 microg/kg/min), 183 group I segments (68%) and 438 group II (39%) segments had contractile reserve (p <0.0001). However, functional recovery was observed less frequently in group I segments (41%) than in group II segments (55%) with contractile reserve (p <0.005). During high-dose DSE (up to 40 microg/kg/min), in the group I segments with contractile reserve at the low dose, the sustained improvement pattern (indicating subendocardial scar) was prevalent (73%). After revascularization, 73% of segments with sustained improvement did not recover. Conversely, the biphasic response (indicating ischemically jeopardized myocardium) was observed only in 27% of group I segments. Functional recovery occurred in 39 of these segments (78%) (p <0.001 vs sustained improvement). Hence, mildly hypokinetic segments probably indicate the presence of subendocardial scars, and may explain the failure in functional recovery after revascularization.

Adult↗
PubMed2004

Prediction of all-cause mortality in women with known or suspected coronary artery disease by stress technetium-99m tetrofosmin myocardial perfusion imaging.

We studied the incremental value of stress technetium-99m tetrofosmin imaging for predicting all-cause mortality in 503 women (aged 58 +/- 12 years) with known or suspected coronary artery disease. The annual mortality rate was 1.4% with normal perfusion and 4% with abnormal perfusion (p <0.01) during a follow-up of 3.5 +/- 1.2 years. In an incremental multivariate analysis model, clinical predictors of mortality were age, diabetes mellitus, smoking, and a lower systolic blood pressure during stress. An abnormal scan was incremental to clinical data in predicting mortality.

Aged↗
PubMed2004

Association between long-term statin use and mortality after successful abdominal aortic aneurysm surgery.

PURPOSE: To assess the potential long-term beneficial effects of statin use after successful abdominal aortic surgery. METHODS: Between 1991 and 2001, 570 patients underwent abdominal aortic aneurysm repair at the Erasmus Medical Center. Of the 519 patients (91%) who survived surgery beyond 30 days, 510 (98%) were followed for a median of 4.7 years (interquartile range, 2.7 to 7.3 years). These patients were evaluated for use of statins and beta-blockers, and for clinical risk factors (e.g., advanced age; prior myocardial infarction; diabetes mellitus; renal dysfunction; chronic pulmonary disease; history of heart failure, stroke, or angina), and their association with all-cause and cardiovascular mortality. RESULTS: A total of 205 patients (40%) died during follow-up; 140 due to cardiovascular causes. The incidence of all-cause (18% [27/154] vs. 50% [178/356], P <0.001) and cardiovascular (11% [17/154] vs. 34% [122/356], P <0.001) mortality was significantly lower in statin users than in nonstatin users. After adjusting for clinical risk factors and beta-blocker use, the association between statin use and reduced all-cause (hazard ratio [HR] = 0.4; 95% confidence interval [CI]: 0.3 to 0.6; P <0.001) and cardiovascular (HR = 0.3; 95% CI: 0.2 to 0.6; P <0.001) mortality persisted. Beta-blocker use was also associated with a significant reduction in all-cause (HR = 0.6; 95% CI: 0.5 to 0.9; P = 0.003) and cardiovascular (HR = 0.7; 95% CI: 0.4 to 0.9; P = 0.03) mortality. There was no evidence of an association between statin use and all-cause and cardiovascular mortality according to beta-blocker use or clinical risk factors. CONCLUSION: Long-term statin use is associated with reduced all-cause and cardiovascular mortality irrespective of clinical risk factors and beta-blocker use.

Adrenergic beta-Antagonists↗
PubMed2004

Incidence of recovery of contractile function following revascularization in patients with ischemic left ventricular dysfunction.

Contractile function in patients with ischemic left ventricular (LV) dysfunction may improve after myocardial revascularization. Currently, the incidence of contractile function recovery after revascularization in these patients is unclear. The aim of this study was to assess the incidence of function improvement after myocardial revascularization in patients with ischemic LV dysfunction. A total of 258 consecutive patients (aged 59 +/- 12 years) with severely depressed LV ejection fractions (EFs) due to chronic coronary artery disease and heart failure symptoms were studied. All patients underwent radionuclide ventriculography and 2-dimensional echocardiography at rest before and 3 to 6 months after revascularization. At baseline, 1,330 segments (32%) were normal and 2,775 segments (68%) were dysfunctional. Improvement after revascularization occurred in 736 of the 2,775 dysfunctional segments (27%). Overall, LVEF improved from 29 +/- 7 to 32 +/- 9 (p <0.0001). A clinically significant improvement of LVEF (>/=5% postrevascularization) was present in 101 patients (39%). Improvement of LVEF after revascularization was frequently observed in patients with a more severely impaired baseline LVEF. At least 3 segments with improvement of function were needed for an improvement of LVEF of >/=5%.

Coronary Artery Disease↗
PubMed2004

Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery.

PURPOSE: To determine the incidence of perioperative events in patients with aortic stenosis undergoing noncardiac surgery. METHODS: We studied 108 patients with moderate (mean gradient, 25 to 49 mm Hg) or severe (mean gradient, > or =50 mm Hg) aortic stenosis and 216 controls who underwent noncardiac surgery between 1991 and 2000 at Erasmus Medical Center. Controls were selected based on calendar year and type of surgery. Details of clinical risk factors, type of surgery, and perioperative management were retrieved from medical records. The main outcome measure was the composite of perioperative mortality and nonfatal myocardial infarction. RESULTS: There was a significantly higher incidence of the composite endpoint in patients with aortic stenosis than in patients without aortic stenosis (14% [15/108] vs. 2% [4/216], P <0.001). This rate of perioperative complications was also substantially higher in patients with severe aortic stenosis compared with patients with moderate aortic stenosis (31% [5/16] vs. 11% [10/92], P = 0.04). After adjusting for cardiac risk factors, aortic stenosis remained a strong predictor of the composite endpoint (odds ratio = 5.2; 95% confidence interval: 1.6 to 17.0). CONCLUSION: Aortic stenosis is a risk factor for perioperative mortality and nonfatal myocardial infarction, and the severity of aortic stenosis is highly predictive of these complications.

Adult↗
PubMed2004

Pulsed-wave tissue Doppler quantification of systolic and diastolic function of viable and nonviable myocardium in patients with ischemic cardiomyopathy.

BACKGROUND: Detection of myocardial viability is crucial for clinical treatment of patients with ischemic cardiomyopathy. Currently, quantitative information for the evaluation of systolic and diastolic function of viable tissue is limited. Our aim was to compare quantitatively systolic and diastolic function in viable and nonviable dysfunctional myocardium in patients with ischemic cardiomyopathy. METHODS: A total of 93 patients (mean age, 62 +/- 10 years) underwent dobutamine stress echocardiography to assess myocardial viability. Pulsed-wave tissue Doppler imaging (TDI) was used to assess systolic ejection velocity (V(S)) and early (V(E)) and late (V(A)) diastolic velocities at rest and at low-dose dobutamine infusion (10 microg/kg per minute) in viable and nonviable dysfunctional regions. Analysis was repeated after dividing study population in patients >or=65 years old (n = 40) and <65 years old (n = 53). RESULTS: Pulsed-wave TDI demonstrated that V(S) was comparable in dysfunctional viable and nonviable regions at rest (V(S), 6.3 +/- 1.9 cm/s vs 6.3 +/- 2.0 cm/s, respectively, P = .93). However, at low-dose dobutamine challenge, V(S) was significantly higher in viable regions (8.5 +/- 2.7 cm/s vs 7.8 +/- 2.4 cm/s, P = .002). Viable regions had higher V(E) at rest compared with nonviable regions (8.4 +/- 2.5 cm/s vs 7.5 +/- 2.8 cm/s, P = .003). Myocardial velocities were significantly higher in patients >or=65 years old, both in viable and nonviable regions. CONCLUSIONS: Quantification of myocardial motion by pulsed-wave TDI demonstrates that at low-dose dobutamine stress, systolic velocity is markedly improved in viable myocardium, indicating the presence of contractile reserve in viable regions. A superior early diastolic filling at rest can also differentiate viable from nonviable myocardium.

Adult↗
PubMed2004

Prognostic value of dobutamine stress echocardiography in patients with normal left ventricular systolic function.

BACKGROUND: Patients with normal left ventricular systolic function are considered to be at a relatively low risk for cardiac events. There are scarce data regarding association of ischemia on stress imaging techniques with outcome in these patients. OBJECTIVES: We sought to assess the prognostic significance of dobutamine-induced myocardial ischemia for patients with normal left ventricular systolic function. METHODS: We studied 528 patients with normal baseline left ventricular systolic function who underwent high-dose dobutamine-atropine stress echocardiography and were followed up for 4.7 +/- 2.1 years for occurrence of death and hard cardiac events (cardiac death and nonfatal myocardial infarction). RESULTS: Ischemia (new wall-motion abnormalities) was detected in 127 patients (24%). Follow-up events were death in 69 patients (13%) and hard cardiac events in 55 patients (10%). The annual hard cardiac event rate was 5% for patients with ischemia and 1.1% for patients without. In a multivariate analysis model, ischemia was the only independent predictor of hard cardiac events (risk ratio [RR] 4.3, 95% confidence intervals [CI] 2.5-7.4). Predictors of all causes of mortality were advanced age (RR 1.08, CI 1.05-1.11), higher resting rate pressure product (RR 1.11, CI 1.02-1.22), and ischemia (RR 2.1, CI 1.2-3.6). CONCLUSION: Dobutamine-induced wall-motion abnormalities are independently associated with increased risk of all-cause mortality and hard cardiac events in patients with normal baseline left ventricular function.

Dobutamine↗
PubMed2004

Why do patients with ischemic cardiomyopathy and a substantial amount of viable myocardium not always recover in function after revascularization?

OBJECTIVE: In patients with ischemic cardiomyopathy and a substantial amount of dysfunctional but viable myocardium, myocardial revascularization may improve left ventricular ejection fraction. The aim of this study was to evaluate why not all patients with a substantial amount of viable tissue recover in function after revascularization. METHODS: A total of 118 consecutive patients with a depressed left ventricular ejection fraction (on average 29% +/- 6%) due to chronic coronary artery disease underwent myocardial revascularization. Before revascularization all patients underwent dobutamine stress echocardiography to assess regional dysfunction, left ventricular volumes, and myocardial viability as well as radionuclide ventriculography to determine the left ventricular ejection fraction. Next, 3 to 6 months after revascularization, the left ventricular ejection fraction and regional contractile function were reassessed. Improvement of left ventricular ejection fraction > or = 5% following revascularization was considered clinically significant. RESULTS: Dobutamine stress echocardiography revealed that 489 (37%) of the 1329 dysfunctional segments were viable. A total of 61 (52%) patients had a substantial amount of viable myocardium (> or = 4 viable segments). In these 61 patients the global function was expected to recover > or = 5% after revascularization. However, left ventricular ejection fraction did not improve in 20 (33%) of 61 patients despite the presence of substantial viability. Clinical characteristics and echocardiographic data were comparable between patients with and without improvement. However, patients without improvement had considerably larger end systolic volumes (153 +/- 41 mL vs 133 +/- 46 mL, P =.007). The likelihood of recovery of global function decreased proportionally with the increase of end systolic volume (P <.001, R = 0.43, n = 61). Receiver operating characteristic curve analysis demonstrated that an end systolic volume > or = 140 mL had the highest sensitivity/specificity to predict the absence of global recovery. CONCLUSIONS: In patients with ischemic cardiomyopathy not only the amount of dysfunctional but viable myocardium but also the extent of left ventricular remodeling determines the improvement in function following myocardial revascularization. Patients with a high end systolic volume due to left ventricular remodeling have a decreased likelihood of improvement of global function.

Aged↗
PubMed2004

Cost-effectiveness of differing perioperative beta-blockade strategies in vascular surgery patients.

OBJECTIVES: To determine the incremental value of different strategies of both oral and intravenous beta-blockade during the perioperative period in high-risk vascular patients in reducing costs and improving outcomes. DESIGN: Decision analytic model incorporating costs from provider's perspective INTERVENTIONS: Five perioperative strategies in patients undergoing abdominal aortic aneurysm surgery: (1). no routine beta-blockade, (2). preoperative oral bisoprolol for 7 days followed by perioperative intravenous metoprolol and oral bisoprolol based on preoperative titration, (3). immediate preoperative atenolol with postoperative intravenous then oral atenolol, (4). intraoperative esmolol and postoperative intravenous then oral atenolol, and (5). intraoperative and 18 hours of postoperative esmolol then atenolol. MEASUREMENTS AND MAIN RESULTS: Perioperative death was associated with a net increase of US dollars 21909 in charges to Medicare, whereas sustaining a perioperative myocardial infarction was associated with a net increase in charges of US dollars 15000. There is a net hospital saving of US dollars 500 using a strategy of titration of an oral beta-blocker medication for a minimum of 7 days, with a net increase in efficacy of 0.0304. All of the strategies involving acute perioperative blockade were associated with a net cost savings and increase in efficacy, although less than the strategy involving preoperative oral titration. CONCLUSION: Perioperative beta-blockade is both cost effective as well as efficacious from a short-term provider perspective. The optimal strategy of treatment for patients who do not present to surgery already on beta-blockers requires further study, although all strategies save money even accounting for pharmaceutical costs.

Administration, Oral↗
PubMed2004

Does resting two-dimensional echocardiography identify patients with ischemic cardiomyopathy and low likelihood of functional recovery after coronary revascularization?

OBJECTIVE: To evaluate the potential of a simple and widely available technique as two-dimensional (2D) echocardiography to identify patients with ischemic cardiomyopathy and low likelihood of functional recovery after coronary revascularization. METHODS: Two-dimensional echocardiography and radionuclide ventriculography (RNV) were performed before coronary revascularization in 94 patients with ischemic cardiomyopathy. Left ventricular ejection fraction (LVEF) was measured by RNV. Regional wall motion abnormalities, wall motion score index, end-diastolic wall thickness (EDWT), left ventricular (LV) volumes and LV sphericity index were assessed in the echocardiographic images. RNV was repeated 9-12 months after revascularization to assess LVEF change; an improvement >or=5% was considered clinically significant. RESULTS: Nine hundred and ninety-nine segments were severely dysfunctional; 149 out of 999 (15%) had an EDWT or=100 ml/ml) and of the end-systolic volume index (>or=80 ml) was present in 32 (34%) and 21 (22%) patients, respectively. A spherical shape of the LV was observed in 35 (37%) patients. LVEF after revascularization increased in 30 out of 94 patients (32%) from 30+/-8% to 39+/-9% (P<0.0001). On multivariate analysis, the EDVI was the only predictor of no recovery in LVEF [odds ratio, 1.06, confidence interval (CI), 1.04-1.1, P<0.0001]. The cut-off value of EDVI >or=90 ml/ml accurately identified patients that virtually never recover. Post-operatively, LVEF increased in three out of 42 (7%, 95% CI 0-15%) patients with EDVI >or=90 ml/ml as compared to 27 out of 52 (52%) patients with EDVI<90 ml/ml (P<0.0001). CONCLUSIONS: In patients with ischemic cardiomyopathy and severe LV enlargement, improvement of LVEF after revascularization is unlikely to occur. Conversely, in patients with relatively preserved LV size, a higher likelihood of functional recovery may be anticipated.

Aged↗
PubMed2004

Methodological analysis of diagnostic dobutamine stress echocardiography studies.

BACKGROUND: Dobutamine stress echocardiography (DSE) is an accepted test for the diagnosis of coronary artery disease (CAD), despite its wide diagnostic accuracy. AIM: Which factors cause test variability of DSE for the diagnosis of CAD. METHODS: In a retrospective analysis of 46 studies in 5,353 patients, the potential causes of diagnostic variability were systematically analyzed, including patient selection, definition of CAD, chest pain characteristics, confounding factors for DSE (left ventricular hypertrophy, left bundle branch block, female gender), work-up bias (present when patient's chance to undergo coronary angiography is influenced by the result of DSE), review bias (present when DSE is interpreted in relation to CAG), DSE protocol and definition of a positive DSE. RESULTS: Diagnostic variability was related to definition of a positive test, but not related to the definition of CAD or DSE protocol. However, only three of eight methodological standards for research design found general compliance. Differences in the selection of the study population (quality of echocardiographic window, angina pectoris), handling of confounding factors and analysis of disease in individual coronary arteries were observed. Lack of data on analysis of relevant chest pain syndromes and handling of nondiagnostic test results hampered further evaluation of these standards. CONCLUSION: Methodological problems may explain the wide range in diagnostic variability of DSE. An improvement of clinical relevance of DSE testing is possible by stronger adherence to common and new methodological standards.

Coronary Artery Disease↗
PubMed2004

Comparison of catecholamine hormone release in patients undergoing carotid artery stenting or carotid endarterectomy.

PURPOSE: To investigate the pattern of catecholamine response in patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS). METHODS: Adrenaline, noradrenaline, and renin levels were measured at 5 time points in 12 patients undergoing 13 CEAs (1 bilateral) and 13 patients undergoing unilateral CAS. Arterial blood samples were taken at the following time points: (1) after induction in CEA patients or 5 minutes following first contrast injection in CAS patients, (2) 5 minutes following ICA clamp release in surgical patients or deflation of the balloon in the CAS cohort, (3) 60 minutes following ICA clamp release in surgical patients or deflation of the balloon in the CAS cohort, and (4) 24 hours following the procedure. Intraoperative blood pressure and heart rate were recorded using radial arterial monitoring. Changes in adrenaline, noradrenaline, and renin levels are expressed as ratios versus baseline. RESULTS: Patterns of adrenaline and noradrenaline release were significantly different in patients undergoing CAS and CEA, with much higher and more variable surges of adrenaline and noradrenaline occurring in CEA patients. Adrenaline and noradrenaline levels increased significantly over baseline following carotid artery clamping in patients undergoing CEA (noradrenaline ratio before clamping: 1.54+/-1.25, 24 hours after unclamping: 8.38+/-16.35 [p<0.001]; adrenaline ratio before clamping: 1.12+/-0.49, 60 minutes after unclamping: 17.59+/-19.14 [p<0.001]). Conversely, in patients undergoing CAS, catecholamine levels remained unchanged (noradrenaline ratio before dilation: 0.96+/-0.23, 24 hours after the procedure: 0.92+/-0.32 [p=NS]; adrenaline ratio before dilation: 0.83+/-0.33, 60 minutes after balloon deflation: 0.56+/-0.32 [p=NS]). CONCLUSIONS: CAS is associated with a significantly less marked catecholamine response than CEA, which may reflect down-regulation of the sympathetic nervous system in response to carotid sinus stimulation during carotid angioplasty.

Aged↗
PubMed2003

Catheter-based intramyocardial injection of autologous skeletal myoblasts as a primary treatment of ischemic heart failure: clinical experience with six-month follow-up.

OBJECTIVES: We report on the procedural and six-month results of the first percutaneous and stand-alone study on myocardial repair with autologous skeletal myoblasts. BACKGROUND: Preclinical studies have shown that skeletal myoblast transplantation to injured myocardium can partially restore left ventricular (LV) function. METHODS: In a pilot safety and feasibility study of five patients with symptomatic heart failure (HF) after an anterior wall infarction, autologous skeletal myoblasts were obtained from the quadriceps muscle and cultured in vitro for cell expansion. After a culturing process, 296 +/- 199 million cells were harvested (positive desmin staining 55 +/- 30%). With a NOGA-guided catheter system (Biosense-Webster, Waterloo, Belgium), 196 +/- 105 million cells were transendocardially injected into the infarcted area. Electrocardiographic and LV function assessment was done by Holter monitoring, LV angiography, nuclear radiography, dobutamine stress echocardiography, and magnetic resonance imaging (MRI). RESULTS: All cell transplantation procedures were uneventful, and no serious adverse events occurred during follow-up. One patient received an implantable cardioverter-defibrillator after transplantation because of asymptomatic runs of nonsustained ventricular tachycardia. Compared with baseline, the LV ejection fraction increased from 36 +/- 11% to 41 +/- 9% (3 months, p = 0.009) and 45 +/- 8% (6 months, p = 0.23). Regional wall analysis by MRI showed significantly increased wall thickening at the target areas and less wall thickening in remote areas (wall thickening at target areas vs. 3 months follow-up: 0.9 +/- 2.3 mm vs. 1.8 +/- 2.4 mm, p = 0.008). CONCLUSIONS: This pilot study is the first to demonstrate the potential and feasibility of percutaneous skeletal myoblast delivery as a stand-alone procedure for myocardial repair in patients with post-infarction HF. More data are needed to confirm its safety.

Aged↗
PubMed2003

Long-term prognosis after normal dobutamine stress echocardiography.

Patients with normal dobutamine stress echocardiography (DSE) were shown to have a favorable outcome at an intermediate-term follow-up. However, there are scarce data regarding long-term survival after normal DSE. This study sought to assess the long-term outcome after normal DSE. We studied 401 patients (age 62 +/- 10 years, 264 men) who had a normal echocardiogram at rest and with high-dose dobutamine stress. End points during a mean follow-up of 5 +/- 1.7 years (minimum 3.5) were all-cause mortality and hard cardiac events (cardiac death and nonfatal myocardial infarction). During follow-up, 45 patients (11%) died due to various causes (cardiac death in 10 patients). Thirteen patients had nonfatal myocardial infarction (a total of 23 hard cardiac events). The annual mortality rate was 2% in the first 3 years and 2.4% between the fourth and sixth years. The annual hard cardiac event rate was 0.8% in the first 3 years and 1.7% between the fourth and sixth years. Predictors of mortality in a multivariate analysis model were advanced age (hazard ratio 1.2, 95% confidence interval CI 1.1 to 1.4) and higher heart rate at rest (hazard ratio 0.92, 95% confidence interval 0.85 to 0.99). Patients with normal DSE had excellent outcomes during the 3 years after the study. The cardiac event rate was higher between the fourth and sixth year; therefore, it may be useful to repeat the study after 3 years to reassess risk status.

Cardiotonic Agents↗
PubMed2003

Prognostic significance of fixed perfusion abnormalities on stress technetium-99m sestamibi single-photon emission computed tomography in patients without known coronary artery disease.

Fixed perfusion abnormalities in patients with known coronary artery disease (CAD) are associated with myocardial damage and adverse outcomes. However, the significance of these abnormalities in patients without known CAD is unclear. The aim of this study was to assess the prognostic significance of fixed versus reversible perfusion abnormalities in patients without known CAD. We studied 327 patients (58 +/- 11 years of age; 215 men) with no history of myocardial infarction or revascularization, who demonstrated myocardial perfusion abnormalities on stress (exercise or dobutamine) sestamibi tomographic imaging. Follow-up end points were all-cause mortality and hard cardiac events (cardiac death and nonfatal myocardial infarction). Myocardial perfusion abnormalities were reversible in 226 patients (69%) and fixed in 101 patients (31%). During a mean follow-up of 7 years, 72 patients (22%) died (cardiac death in 30) and 15 patients had nonfatal myocardial infarctions. The annual mortality rate was higher in patients with fixed abnormalities than in those with reversible abnormalities (4.4% vs 2.7%, p <0.01), whereas the annual hard cardiac event rate was not significantly different between the 2 groups (2.5% vs 2%). In a multivariate analysis model, the summed stress score was an independent predictor of hard cardiac events (risk ratio 1.7, 95% confidence interval 1.3 to 5.4). The presence of a fixed perfusion abnormality was independently associated with an increased risk of death after adjustment for clinical and stress test data and the summed stress score (risk ratio 2.5, 95% confidence interval 1.3 to 3.7). In patients with suspected, but no history of CAD, fixed perfusion abnormalities were associated with a higher risk of death compared with reversible perfusion abnormalities.

Adult↗
PubMed2003

Optimizing long-term cardiac management after major vascular surgery: Role of beta-blocker therapy, clinical characteristics, and dobutamine stress echocardiography to optimize long-term cardiac management after major vascular surgery.

BACKGROUND: Survivors of major vascular surgery are at increased risk of late cardiac complications. OBJECTIVE: To examine the cardioprotective effect of beta-blockers. METHODS: A follow-up study was conducted in 1286 patients who survived surgery for at least 30 days. Patients were screened for cardiac risk factors and dobutamine stress echocardiography (DSE) results; 1034 patients (80%) underwent preoperative DSE, and 370 (29%) received beta-blockers. The main outcome measure was late cardiac death or myocardial infarction. RESULTS: Seventy-four patients (5.8%) had late cardiac events. Cardiac event rates in patients with 0, 1 to 2, and 3 or more risk factors were 1.6%, 4.7%, and 19.2%, respectively. In patients without risk factors, beta-blockers were associated with improved event-free survival (2.8% vs 0%), and DSE had no additional prognostic value. In patients with 1 to 2 risk factors, the presence of ischemia during DSE increased cardiac events from 3.9% to 9.8%. However, if patients with ischemia were treated with beta-blockers, the risk decreased to 7.2%. In patients with 3 or more risk factors, DSE and beta-blockers stratified patients into intermediate- and high-risk groups. In patients without ischemia, beta-blockers reduced the cardiac event rate from 15.1% to 9.5%, whereas the cardioprotective effect was limited in patients with 3 or more risk factors and positive DSE findings. CONCLUSIONS: Long-term beta-blocker use is associated with a reduction in the cardiac event rate, except for patients with 3 or more risk factors and positive findings on DSE.

Adrenergic beta-Antagonists↗