Meeting Highlights


Perioperative Beta-blockade Improves Carotid Endarterectomy Outcomes

Presented by George Galyfos, Greece

Perioperative beta-blockade in patients with coronary artery disease (CAD) undergoing carotid endarterectomy (CEA) appeared to prevent cardiac damage, resulting in a low mortality rate and no stroke events. George Galyfos, MD, Hippocration Hospital, Athens, Greece, presented data from a study evaluating the role of beta blockage in asymptomatic cardiac damage in patients with CAD undergoing CEA.

The death rate after undergoing CEA is up to 50%, with most deaths occurring within the first 48 hours. Therefore, CEA is considered to be a procedure of intermediate cardiac risk according to the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines. In 2009, both the ACC/AHA and European Society of Cardiology (ESC) guidelines recommended preoperative beta-blockade with dose titration as Class IIa evidence [Bouri S et al. Heart 2013]. In addition, a review found that in most studies, beta-blockade in patients undergoing vascular surgery found a decrease in cardiovascular events, mortality, heart rate, and blood pressure compared with control; however, there was also an increased risk of bradycardia and mortality [Brooke BS, J Vasc Surg 2010]. The purpose of this study was to further evaluate the effect of beta-blockade on the outcomes of patients undergoing CEA.

In the present study, 162 patients with CAD who were expected to undergo CEA were randomly assigned to either receive a beta-blocker (n=70) or not (n=92). In addition, patients were categorized into 3 groups (low, medium, or high cardiac risk) according to their Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) score [Bertges et al. J Vasc Surg 2010]. Based on VSG-RCI, most patients with low cardiac risk were asymptomatic (64%), whereas a majority of patients at high cardiac risk had a previous history of transient ischemic attack (TIA) or amaurosis (83%).

Patients who received beta-blockade prior to CEA demonstrated less cardiac damage compared with patients who did not undergo beta-blockade (odds ratio, 0.25; 95% CI, 0.08 to 0.77; p=0.01). Following the CEA procedure, there were no strokes overall and no events were observed in patients at high cardiac risk. In addition, 14% of patients experienced asymptomatic cardiac damage within the first 72 hours, but there were no cases of symptomatic cardiac damage. The mortality rate in the study was 0.6%.

Interestingly, troponin levels increased by the first day after CEA for patients at low and intermediate cardiac risk, but not for patients at high cardiac risk (Table 1). At Days 3 and 7, the troponin levels decreased in patients at low and intermediate risk, but remained the same for patients at high risk. This suggests that patients at high-risk receive the greatest benefit from beta-blockade.

In conclusion, Dr. Galyfos stated that data from this study indicate that perioperative administration of beta-blockers appears to provide a protective effect from cardiac damage in patients with CAD undergoing CEA. In addition, he called for more trials with less bias to examine the benefit of beta-blockade in this population.