Journal of Cardiothoracic and Vascular Anesthesia
Volume 21, Issue 3 , Pages 323-324, June 2007

The Preoperative Evaluation: An Opportunity for Education and Other Strategies to Improve Care

Department of Anesthesiology & Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA

Article Outline

 

IT HAS BEEN well recognized for almost half a century that the preoperative interview, in addition to an opportunity to obtain a thorough history, is a critical time to both impart information to the patient and attempt to relieve their anxiety.1, 2 With the change from a system wherein patients are admitted the night before surgery to a system in which patients present the morning of surgery, the ability of the anesthesiologist to be both an educator and initiate the premedication have been diminished. This change has led to the development of preoperative screening clinics in which much of this information is frequently imparted by nonanesthesiologists.3 It is therefore critical that anesthesiologists ensure that medication and education protocols are established in these clinics to ensure best care. In this issue of the Journal, Rosenfeld et al4 showed the lack of education and understanding of patients with regard to the importance of continuing specific medications (eg, β-blockers, as a means of reducing the cardiac risk of noncardiac surgery).

Up until the last decade, the focus was on the use of the patient’s history and diagnostic testing as a means of identifying those at greatest risk of perioperative cardiac morbidity after noncardiac surgery.5 Although the potential concerns of beta-blocker withdrawal were known from the early work of Prys-Roberts et al,6 the importance of establishing a perioperative β-blocker protocol was not well established. It was simply believed that β-blockers should not be withheld before surgery. Despite this belief, it was still acceptable to withhold β-blockers in the placebo arm of the randomized trial of atenolol by Mangano and colleagues.7 With another class of cardioprotective medications, statins, the recommendation in the Physician’s Desk Reference is to also withhold this medication perioperatively.

In the author’s clinical practice, patients frequently present on the day of surgery with wide variability in having taken their cardiovascular medications preoperatively. The current study may help explain some of this variability, as shown by the lack of appropriate education and understanding of their importance. Rosenfeld and colleagues4 reported that only 49% of their patients thought β-blockers were beneficial in the perioperative period, and even then only 7% recalled their prescribing physician mentioning them in relation to surgery. Because educational level did not appear to be a critical factor between those who did and did not recognize the importance of these agents (there was a mean difference of only 1.1 years of education), the authors appropriately point out that it is physician education of the patient that is critical. Based on these results, the author believes this education must be embraced by the anesthesiologist. This is in the best interests of the specialty because there is increased interest by patients in participating in their care.

So, what should clinicians be doing in preoperative clinics and through preoperative telephone calls? Based on the recent American Heart Association/American College of Cardiology Focused Update on Perioperative Beta-Blockade, class I recommendations advise that patients on β-blockers should be continued on β-blockers, and patients with a positive stress test undergoing vascular surgery should be started on β-blockers.8 There are large groups of patients currently not taking β-blockers but who have class I indications for β-blockers independent of noncardiac surgery and for whom these agents could be started as part of a preoperative evaluation. For example, β-blockers should be started and continued indefinitely in all patients who have myocardial infarction, acute coronary syndrome, or left ventricular dysfunction, with or without heart failure symptoms, unless contraindicated.9 As shown in multiple studies, a large percentage of patients present to vascular surgery with a history of a previous myocardial infarction and are not taking β-blockers.10, 11 Such an approach would mimic that of Poldermans and colleagues,12 which showed a benefit to administration begun an average of 7 days before surgery. Importantly, recent evidence suggests that heart rate control is critical to achieving optimal results, potentially with longer-acting agents, and ensuring a protocol is available to minimize any chance of β-blocker withdrawal.13, 14, 15 As the guidelines note and as has been shown in several recent trials, there is a lack of efficacy to suggest that starting β-blockers in patients without known coronary artery disease will be beneficial.16, 17

Finally, it is important to recognize that there are other medications for which the risk of continued administration may outweigh any potential side effect. For example, a recent meta-analysis of statin medications suggests that they should be continued.18 Similarly, aspirin therapy might prove beneficial for reducing coronary artery thrombosis if the risk of bleeding is small.4, 19

In summary, the preoperative clinic or telephone call represents an excellent opportunity to educate the patient in the importance of continuing chronic medications that could potentially reduce the cardiac complications of noncardiac surgery. In those patients who are not on appropriate medications for the long-term treatment of coronary artery disease, the preoperative consultation may represent an opportunity to start these medications by the anesthesiologists themselves or in collaboration with their primary caregivers, acknowledging the importance of developing a perioperative protocol for their administration. The current study by Rosenfeld and colleagues4 reminds clinicians of how far they still have to go.

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References 

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PII: S1053-0770(07)00089-4

doi:10.1053/j.jvca.2007.03.004

Journal of Cardiothoracic and Vascular Anesthesia
Volume 21, Issue 3 , Pages 323-324, June 2007

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