Use of a nurse-led intervention to optimize beta-blockade for reducing cardiac events after major noncardiac surgery

Marwick, Thomas H., Branagan, Helen, Venkatesh, Bala, Stewart, Simon, STRATIFY investigators, Walker, Philip and Stanton, Tony (2009) Use of a nurse-led intervention to optimize beta-blockade for reducing cardiac events after major noncardiac surgery. American Heart Journal, 157 4: 784-790. doi:10.1016/j.ahj.2008.09.014

Author Marwick, Thomas H.
Branagan, Helen
Venkatesh, Bala
Stewart, Simon
STRATIFY investigators
Walker, Philip
Stanton, Tony
Title Use of a nurse-led intervention to optimize beta-blockade for reducing cardiac events after major noncardiac surgery
Journal name American Heart Journal   Check publisher's open access policy
ISSN 0002-8703
Publication date 2009-04
Year available 2009
Sub-type Article (original research)
DOI 10.1016/j.ahj.2008.09.014
Volume 157
Issue 4
Start page 784
End page 790
Total pages 7
Editor Daniel B. Mark
Place of publication St. Louis, Mo., United States of America
Publisher Mosby
Language eng
Subject 110201 Cardiology (incl. Cardiovascular Diseases)
Formatted abstract
Although guidelines recommend the use of beta-adrenoceptor blocking drugs to reduce cardiac events (CEs) after major noncardiac surgery, trial results have varied between showing benefit, ineffectiveness, and harm. We sought whether optimizing beta-blockade (BB) delivery could make them more effective.

Intermediate risk patients undergoing major noncardiac surgery (n = 400) were randomized to 2 strategies of BB therapy: universal BB (UBB; n = 197) comprising an algorithm-based, nurse-led strategy to optimize dosing and adherence to bisoprolol titration over ≥1 week preoperatively versus usual care (UC; n = 203), whereby BB are continued in those already taking them or prescribed for patients identified as high risk based on ischemia (new or inducible wall motion abnormalities) at dobutamine echocardiography (DbE). Daily electrocardiogram and troponin levels were obtained on 3 postoperative days. The primary end point was a major CE (cardiac death or myocardial infarction) within 30 days.

There were 25 major CEs (6.3%), occurring in 13 (6.6%) of 197 UBB and 12 (5.9%) of 203 UC patients (OR 1.12, 95% CI 0.52-2.39). Independent predictors of CEs were baseline systolic blood pressure (β 1.02, P = .005) and postoperative hypotension (β 1.02, P = .03) but not treatment strategy. Those randomized to UBB had significantly better heart rate control perioperatively, at the cost of bradycardia and hypotension. The negative predictive value of DbE in this study was 95%.

These data confirm a persistent CE rate after major noncardiac surgery despite nurse-led dose titration of bisoprolol. Cardiac events were equivalent to a UC strategy based on DbE results.
Copyright © 2009 Published by Mosby, Inc.

Keyword Randomized controlled trial
Q-Index Code C1
Q-Index Status Provisional Code
Additional Notes Available online 9 December 2008. Phillip Walker is a member of the STRATIFY investigators group.

Document type: Journal Article
Sub-type: Article (original research)
Collections: Excellence in Research Australia (ERA) - Collection
School of Medicine Publications
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Citation counts: TR Web of Science Citation Count  Cited 3 times in Thomson Reuters Web of Science Article | Citations
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Created: Thu, 03 Sep 2009, 08:19:14 EST by Mr Andrew Martlew on behalf of Medicine - Princess Alexandra Hospital