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Posts Tagged ‘beta blockers’

As reported at the heart.org, in an article by Michael R’iodan, a recent study completed in the Netherlands showed a heightened risk of post-operative myocardial infarction (MI or heart attack) in the first few weeks after orthopedic surgery (Hip and knee replacement).  This study showed patients to have an up to a 25X increased risk of heart attack in this post-operative period – the risk was particularly acute in the elderly and in patients with previous diagnosis of cardiac disease.

This highlights the importance of pre-operative screening, aggressive medical management of co-morbid conditions during and after surgery, and detecting the sometimes ‘missed’ post-operative MI.  Patients should be carefully evaluated for the presence of angina, or risk factors contributing to the development of coronary artery disease such as hypertension, hypercholesteremia, peripheral vascular disease or diabetes.

Critical medications such beta blockers and statins should be continued during and after surgery.  Medications such as aspirin should be evaluated (and in many cases) continued.

Studies such as this shouldn’t surprise medical professionals – they just confirm what we already know, and should encourage evidence based practice and careful pre-operative screening and co-morbidity management.

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In previous posts, we’ve talked about prevention and management of respiratory complications of lung surgery. However, one of the more common complications of lung surgery, is atrial fibrillation, or an abnormal heart rate and rhythm.

Developing atrial fibrillation is problematic for patients because it increases length of stay (while we attempt to treat it) and increases the risk of other problems (such as stroke – particularly if we can’t get the heart rhythm to return to normal).

‘The Cootie Factor’
Length of stay is important for more than cost and convenience. One of the things I try to explain to my patients – is that hospitals are full of sick people, and in general, my surgery patients are not sick – they’ve had surgery..
But surgery increases their chance and susceptibility to contracting infections from other patients, and visitors. I call this ‘the cootie factor’. (Everyone laughs when you say cooties – but everyone knows exactly what you mean.) So the reason I am rushing my patients out the door is more than just for patient convenience and the comforts of home – it’s to prevent infection, and other serious complications that come from being hospitalized, in close quarters, with people who have may have some very bad cooties indeed (MRSA, resistant Klebsiella, VRE, Tuberculosis and other nasties.)

But besides, length of stay – atrial fibrillation, or a very rapid quivering of the atrial of the heart (250+ times per minute) increases the chance of clots forming within the atrial of the heart, and then being ejected by the ventricles straight up into central circulation – towards the brain – causing an embolic stroke.. Now that’s pretty nasty too..

But there are some easy things we can do to reduce the chance of this happening..
One of the easiest ways to prevent / reduce the incidence of post-operative atrial fibrillation – is to slow down the heart rate. We know that just by slowing down the heart by 10 – 15 beats per minute, we can prevent abnormal heart rhythms.

Most of the time we do this by pre-operative beta blockade, which is a fancy term for using a certain class of drugs, beta blockers (such as metoprolol, carvedilol, atenolol) to slow the heart rate, just a little bit before, during and after surgery.

In fact, this is so important – national/ and international criteria uses heart rate (and whether patients received these medications prior to surgery) as part of the ‘grading’ criteria for rating surgery/ surgeons/ and surgery programs. It’s part of both NSQIPs and the Surgical Apgar Scale – both of which are important tools for preventing intra-operative and post-operative problems..

The good thing is, most of these drugs are cheap (on the $4 plan), very safe, and easily tolerated by patients. Also, most patients only need to be on these medications for a few days before and after surgery – not forever.

Now, if you do develop atrial fibrillation (a. fib) after surgery – we will have to give you stronger (more expensive, more side effects) drugs such as amiodarone, or even digoxin (old, but effective) to try to control or convert your heart rhythm back to normal.

If you heart rhythm does not go back to normal in a day or two – we will have to start you on a blood thinner like warfarin to prevent the blood clots we talked about previously. (Then you may have to have another procedure – cardioversion, and more medicines, if it continues, so you can start to see why it’s so important to try to prevent it in the first place.

Research has also looked at statin drugs to prevent atrial fibrillation after surgery – results haven’t been encouraging, but if you are already on cholesterol medications prior to surgery, there are plenty of other reasons for us to continue them during and after surgery.. (Now, since the literature is mixed on whether statins help prevent a. fib – I wouldn’t start them on patients having lung surgery, but that’s a different matter.)

Now Dr. Shu S. Lin, and some of the other cardiac surgeons did some studies down at Duke looking at pre-operative vitamin C (along with quite a few others) and the results have been interesting.. That doesn’t mean patients should go crazy with the supplements.. anything, even Vitamin C can harm you, if taken willy-nilly (though the risk is minimal).

In fact, the evidence was strong enough (and risk of adverse effects was low enough) that we always prescribed it to our pre-operative patients for both heart and lung surgery.  (Heart patients are at high risk of atrial fibrillation too.)  We prescribed 500mg twice a day for a week before surgery, until discharge – which is similar to several studies.
I’ve included some of these studies before – please note most of them focus on atrial fibrillation after heart surgery.
Vitamin C with beta blockers to prevent A. Fib
This is probably my favorite free text about Vitamin C and Atrial fib – it’s my sort of writing style..

Another article on Vitamin C – for pharmacists (note – article is sponsored by Ester C supplements.)
Contrary to popular belief, performing a VATS procedure (versus open surgery) does not eliminate the risk of post-operative atrial fibrillation.

Now Dr. Onaitis, D’Amico and Harpole published some interesting results last year (and of course, as Duke Thoracic surgeons, I am partial) – but I can’t repost hre since it’s limited access articles..

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