Benefits and Harms of Beta Blockers in the Perioperative Period of Non-Cardiac Surgery: A Narrative Review

Atrial fibrillation (AF) is one of the most common complications after cardiac surgery. Many studies have reported an incidence of 20%-40% in patients undergoing open heart surgery, and the peak incidence usually occurs between the postoperative days [Fuller 1989; Aranki 1996; Svedjeholm 2000; Maisel 2001]. AF is commonly self-limited and rarely results in postoperative death. However, postoperative AF (POAF) is often associated with complications, including stroke, heart failure, prolonged hospital stay, and increased costs [Maisel 2001; Bramer 2010]. Many pharmacological methods have been used to prevent this complication, and beta-blockers, which have been investigated in several studies, have demonstrated effectiveness [Ali 1997; Connolly 2003; Crystal 2004; Halonen 2006; Imren 2007]. There is currently a consensus in the use of beta-blockers for the prevention of POAF. However, whether the effect of beta-blockers on POAF is dose dependent has not been widely studied [Coleman 2004; Lucio 2004]. In addition, patients with different racial backgrounds have a different response to metoprolol based on body shape. In addition, the CYP2D6 genotypes are different among white and Asian patients. In this study dose-dependent prophylactic effects of beta-blockers, which were obtained in a single center.

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Faculty Opinions recommendation of Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1138029.596140 ◽

2008 ◽

Author(s):

Gregor Theilmeier ◽

Jan Larmann

Keyword(s):

Cardiac Surgery ◽

Beta Blockers ◽

Meta Analysis

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Faculty Opinions recommendation of Anticoagulant and side-effects of protamine in cardiac surgery: a narrative review.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.733133179.793545572 ◽

2018 ◽

Author(s):

Filip De Somer

Keyword(s):

Cardiac Surgery ◽

Side Effects ◽

Narrative Review

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Preventing Myocardial Injury Following Non-Cardiac Surgery: A Potential Role for Preoperative Antioxidant Therapy with Ubiquinone

Antioxidants ◽

10.3390/antiox10020276 ◽

2021 ◽

Vol 10 (2) ◽

pp. 276

Author(s):

Qun Chen ◽

Steven Qi ◽

Laura Hocum-Stone ◽

Edward Lesnefsky ◽

Rosemary F. Kelly ◽

...

Keyword(s):

High Risk ◽

Heart Diseases ◽

Beta Blockers ◽

Controlled Trial ◽

Oxidant Stress ◽

Perioperative Period ◽

Antioxidant Therapy ◽

Ischemic Heart ◽

Background Information ◽

Swine Model

Over 240 million non-cardiac operations occur each year and are associated with a 15–20% incidence of adverse perioperative cardiovascular events. Unfortunately, preoperative therapies that have been useful for chronic ischemic heart diseases, such as coronary artery revascularization, antiplatelet agents, and beta-blockers have failed to improve outcomes. In a pre-clinical swine model of ischemic heart disease, we showed that daily administration of ubiquinone (coenzyme Q10, CoQ10) enhances the antioxidant status of mitochondria within chronically ischemic heart tissue, potentially via a PGC1α-dependent mechanism. In a randomized controlled trial, among high-risk patients undergoing elective vascular surgery, we showed that NT Pro-BNP levels are an important means of risk-stratification during the perioperative period and can be lowered with administration of CoQ10 (400 mg/day) for 3 days prior to surgery. The review provides background information for the role of oxidant stress and inflammation during high-risk operations and the potential novel application of ubiquinone as a preoperative antioxidant therapy that might reduce perioperative adverse cardiovascular outcomes.

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Local Anesthetics and Recurrence after Cancer Surgery-What’s New? A Narrative Review

Journal of Clinical Medicine ◽

10.3390/jcm10040719 ◽

2021 ◽

Vol 10 (4) ◽

pp. 719

Author(s):

Sarah D. Müller ◽

Jonathan S. H. Ziegler ◽

Tobias Piegeler

Keyword(s):

Tumor Cells ◽

Circulating Tumor Cells ◽

Local Anesthetics ◽

Experimental Studies ◽

Perioperative Period ◽

Cancer Surgery ◽

Narrative Review ◽

Future Research ◽

Inflammatory Stress ◽

Research Activities

The perioperative use of regional anesthesia and local anesthetics is part of almost every anesthesiologist’s daily clinical practice. Retrospective analyses and results from experimental studies pointed towards a potential beneficial effect of the local anesthetics regarding outcome—i.e., overall and/or recurrence-free survival—in patients undergoing cancer surgery. The perioperative period, where the anesthesiologist is responsible for the patients, might be crucial for the further course of the disease, as circulating tumor cells (shed from the primary tumor into the patient’s bloodstream) might form new micro-metastases independent of complete tumor removal. Due to their strong anti-inflammatory properties, local anesthetics might have a certain impact on these circulating tumor cells, either via direct or indirect measures, for example via blunting the inflammatory stress response as induced by the surgical stimulus. This narrative review highlights the foundation of these principles, features recent experimental and clinical data and provides an outlook regarding current and potential future research activities.

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Volatile anaesthetics added to cardiopulmonary bypass are associated with reduced cardiac troponin

Perfusion ◽

10.1177/0267659117701562 ◽

2017 ◽

Vol 32 (7) ◽

pp. 547-553 ◽

Cited By ~ 12

Author(s):

Elena Bignami ◽

Marcello Guarnieri ◽

Marina Pieri ◽

Francesco De Simone ◽

Alcira Rodriguez ◽

...

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Cardiac Troponin ◽

Troponin I ◽

Myocardial Necrosis ◽

Perioperative Period ◽

Cardiac Surgical Procedures ◽

Control Group ◽

Volatile Anaesthetics ◽

Volatile Agents

Background: Every year, over 1 million cardiac surgical procedures are performed all over the world. Reducing myocardial necrosis could have strong implications in postoperative clinical outcomes. Volatile anaesthetics have cardiac protective properties in the perioperative period of cardiac surgery. However, little data exists on the administration of volatile agents during cardiopulmonary bypass. The aim of this study was to assess if volatile anaesthetics administration during cardiopulmonary bypass reduces cardiac troponin release after cardiac surgery. Materials and methods: We retrospectively analysed data from 942 patients who underwent cardiac surgery in a teaching hospital. The only difference between the groups was the management of anaesthesia during CPB. The volatile group received sevoflurane or desflurane while the control group received a combination of propofol infusion and fentanyl boluses. Patients who received volatile anaesthetics during cardiopulmonary bypass (n=314) were propensity-matched 1:2 with patients who did not receive volatile anaesthetics during CPB (n=628). Results: We found a reduction in peak postoperative troponin I, from 7.8 ng/ml (4.8-13.1) in the non-volatile group to 6.8 ng/ml (3.7-11.8) in the volatile group (p=0.013), with no differences in mortality [2 (0.6%) in the volatile group and 2 (0.3%) in the non-volatile group (p=0.6)]. Conclusions: Adding volatile anaesthetics during cardiopulmonary bypass was associated with reduced peak postoperative troponin levels. Larger studies are required to confirm our data and to assess the effect of volatile agents on survival.

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Clinical application of intra-aortic balloon pump in patients with cardiogenic shock during the perioperative period of cardiac surgery

Experimental and Therapeutic Medicine ◽

10.3892/etm.2017.4177 ◽

2017 ◽

Vol 13 (5) ◽

pp. 1741-1748 ◽

Cited By ~ 1

Author(s):

Xuesong Jiang ◽

Zhitao Zhu ◽

Ming Ye ◽

Yan Yan ◽

Junbo Zheng ◽

...

Keyword(s):

Cardiac Surgery ◽

Cardiogenic Shock ◽

Clinical Application ◽

Perioperative Period ◽

Intra Aortic Balloon Pump

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Remimazolam anesthesia for cardiac surgery with cardiopulmonary bypass: a case report

JA Clinical Reports ◽

10.1186/s40981-021-00424-0 ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Kota Saito ◽

Sho Ohno ◽

Makishi Maeda ◽

Naoyuki Hirata ◽

Michiaki Yamakage

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Oxygen Saturation ◽

Anesthetic Management ◽

Perioperative Period ◽

Maze Procedure ◽

Intraoperative Awareness ◽

Case Presentation ◽

Venous Oxygen Saturation ◽

Index Value

Abstract Background Remimazolam has less cardiovascular depressant effects than propofol in non-cardiac surgical patients. However, the efficacy and safety of remimazolam in cardiac surgery with cardiopulmonary bypass (CPB) have not been reported. We present a case of successful anesthetic management using remimazolam in cardiac surgery with CPB. Case presentation A 76-year-old female was scheduled for mitral valve repair, tricuspid annuloplasty, maze procedure, and left atrial appendage closure. We used remimazolam in induction (6.0 mg/kg/h) and maintenance (0.6–1.0 mg/kg/h) of general anesthesia, and the bispectral index value was maintained in the range of 36 to 48 including the period of CPB. Hemodynamics, mixed venous oxygen saturation, and bilateral regional cerebral oxygen saturation were maintained within acceptable ranges. There was no intraoperative awareness/recall or serious complications associated with remimazolam throughout the perioperative period. Conclusions Remimazolam can be used the same as other existing anesthetics in cardiac surgery with CPB.

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Abstract 2887: Peri-Operative Beta-Blockers in Patients Undergoing Non-cardiac Surgery: A Meta-Analysis of 12,306 Patients from Randomized Trials

Circulation ◽

10.1161/circ.118.suppl_18.s_792-b ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Sripal Bangalore ◽

Shruthi Chandrashekhar ◽

Sandeep Pulimi ◽

Franz H Messerli

Keyword(s):

Heart Failure ◽

Cardiac Surgery ◽

Myocardial Ischemia ◽

Randomized Trials ◽

Beta Blockers ◽

Meta Analysis ◽

Increased Risk ◽

All Cause Mortality ◽

Safety Outcomes ◽

Β Blockers

Background: The 2007 ACC/AHA guideline on perioperative evaluation recommends perioperative β-blockers for non-cardiac surgery. However, some clinical trials seem to be at odds with these recommendations. Methods: PUBMED/EMBASE/CENTRAL search for randomized trials (RCTs) evaluating β-blockers for non-cardiac surgery. Efficacy outcomes of all-cause mortality, cardiovascular (CV) mortality, nonfatal MI, nonfatal stroke, heart failure, and myocardial ischemia (30 days), and safety outcomes of perioperative bradycardia, hypotension, and bronchospasm. Results: Among 33 RCTs which evaluated 12,306 patients, β-blockers were not associated with any significant reduction in the risk of all-cause mortality, CV mortality, or heart failure, but were associated with a 35% decrease in nonfatal MI, 64% decrease in myocardial ischemia at the expense of a 101% increase (Figure ) in nonfatal strokes. The beneficial effects were driven mainly by trials with high-bias risk, while analyses of low-biased trials showed a 28% and 101% increase in all-cause mortality and stroke with only a 29% and 59% reduction in nonfatal MI and 59%myocardial ischemia. For the safety outcomes, β-blockers were associated with a significantly increased risk of peri-op bradycardia and peri-op hypotension. Conclusions: In patients undergoing non-cardiac surgery, we estimate that treatment of 1000 patients with β-blockers results in 16 fewer nonfatal MI, but at the expense of 3 disabling strokes and 45 and 59 patients with clinically significant perioperative bradycardia and hypotension respectively, and suggests an increase in all-cause mortality.

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