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PERIOPERATIVE MYOCARDIAL ISCHEMIA & METOPROLOL TITRATION PROTOCOL

Departments of Anesthesia(ADB), Critical Care (ADB, SK), Pharmacy(SK), Clinical Epidemiology(SK), Ottawa Hospital General Campus, 501 Smyth Rd, Ottawa, K1H 8L6.

INTRODUCTION

A protocol was used to identify to patients at risk for perioperative myocardial ischemia or infarction (PMI/I) and provide prophylaxis.

METHODS

Patients with 2 risk criteria (Lee’s Revised Cardiac Risk Index¹ modified to include age), were eligible for the protocol: IHD/CHF/CVD/RF/DM/ high-intermediate risk surgery /age >70 years. PAU patients took metoprolol 25–50mg bid orally for 1–4 weeks before surgery. Perioperatively, heart rate was controlled with intravenous metoprolol and with titrated oral metoprolol postoperatively until hospital discharge plus one month after discharge. With REB approval, we compared the incidence of ICU admissions with PMI/I before and after protocol introduction.

RESULTS

Surgeries included major general, orthopedic, thoracic, and gynecological, but no vascular, trauma, or neurosurgery. Risk criteria in surgical patients during a random month, extrapolated to the first six months of the protocol, suggest >400 patients should have been eligible; 60 patients were actually enrolled. One enrolled patient had PMI/I, but the protocol was violated. Four had metoprolol doses held post-operatively for minor adverse events. ICU admissions with PMI/I were unchanged (2.67 /month).

Incidence of risk factors % Incidence of BB therapy % Mortality % 0 1 2 3 4 Pre-op Intra-op Post-op pre-MI September 2003 surgical population (n=640) 39 36 16 6 3 14 19 NA NA ICU PMI/I admissions Jan 2002-Dec 2003 (n=56) 0 11 34 32 23 28 19 19 30

DISCUSSION

89% of ICU PMI/I admissions in 2002–3 had >2 risk factors, but most had not received beta blockers (BB) perioperatively. Prescriptions for metoprolol in the hospital increased during the period under review, but not in these high-risk patients. PMI/I risk factors are common in the surgical population at the General Campus, especially in those admitted to the ICU. Early experience suggests this protocol is safe but it is underutilized and has not yet reduced ICU admissions with PMI/I. Implementation strategies need to be revised to increase awareness and emphasize the potential impact of perioperative BB².

REFERENCES

1 Circulation 100:1043–9.

2 N Engl J Med 335:1713–20.

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