Reducing cardiac risk in non-cardiac surgery: evidence from the DECREASE studies
1 Department of Vascular Surgery, Erasmus University Hospital, Erasmus Medical Center Room H921, s-Gravendijkwal 230, 3015 GD Rotterdam, The Netherlands
2 Department of Cardiology, Leiden Medical Centre, Leiden, The Netherlands
* Corresponding author. Tel: +31 10 703 46 13, Fax: +31 10 436 26 95, Email: d.poldermans{at}erasmusmc.nl
Ischaemic cardiac events are a major cause of perioperative morbidity and mortality in non-cardiac surgery; 10–40% of the perioperative deaths are due to myocardial infarction (MI). Drugs that influence myocardial oxygen balance (e.g. beta-blockers) or improve plaque stability (e.g. statins) would be expected to reduce perioperative MI. Evidence for the benefit of beta-blockers in high-risk patients undergoing non-cardiac surgery comes from various studies including the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) study, in which perioperative bisoprolol significantly reduced short- and long-term cardiac death and MI. DECREASE IV found that bisoprolol also significantly reduced 30-day cardiac death and MI in intermediate-risk patients, with a non-significant trend towards a beneficial effect of fluvastatin XL. DECREASE III showed that in high-risk patients undergoing major vascular surgery, fluvastatin XL reduced myocardial ischaemia and the combined endpoint of cardiovascular death and MI. DECREASE II showed that patients identified as intermediate risk on the basis of clinical assessment did not need pre-operative echocardiographic cardiac stress testing, provided that they received bisoprolol to maintain tight heart rate control. DECREASE V found that in high-risk patients with extensive stress-induced ischaemia, coronary revascularization (added to tight heart rate control with bisoprolol) did not produce any additional reduction in death and MI.
Key Words: Non-cardiac surgery • Beta-blockers • Perioperative management • Post-operative complications