Stress of surgery hard on the heart

Dorothy Teixeira, a 76-year-old Peabody woman who had a history of chest pains, got even more bad news last summer: She had colon cancer and needed surgery.

In many hospitals, Teixeira would have been taken off her heart medications during and after surgery because of the fear that the drugs – called beta-blockers – might make her heart too sluggish.

But her doctor at Beverly Hospital, Dr. Lawrence Shinbaum, is one of a growing number of anesthesiologists who feel that not only should patients like Teixeira not be taken off beta-blockers, but that many others should be put on the drugs just before and for a week or so after surgery to reduce the risk of cardiac complications.

The issue can be a matter of life and death – but it’s hotly controversial as well.

Two years ago, Dr. Dennis T. Mangano, an anesthesiologist at the VA Medical Center in San Francisco, published a study of 200 patients who had heart disease or were at risk of it and were having noncardiac surgery. He found that atenolol, a beta-blocker, reduced the overall risk of death by 55 percent and the risk of death specifically from cardiac causes by 65 percent. The benefit was most pronounced in the six months after surgery, but persisted for two years.

“We were surprised,” says Mangano. It’s “very exciting.”

Given that 30 million Americans a year have noncardiac surgery and 3 million of them are at high risk for heart disease, wider use of atenolol – and presumably, other beta-blockers – could prevent thousands of deaths a year, he argues.

The problem is that, aside from some supporting research, Mangano’s study is the main evidence that would cause doctors to use beta-blockers more widely for this purpose, and many say that’s just not enough information to act on.

Mangano’s data “are suggestive because it’s such a well-done study, but it is still a relatively small study,” says Dr. Edward Lowenstein, a cardiac anesthesiologist at Massachusetts General Hospital.

Worse yet, it’s unlikely that much more data will be forthcoming, because many beta-blockers are now sold as generic drugs, and manufacturers have little incentive to fund the larger studies that could settle the issue.

That means doctors have to go with their guts on this one, and their guts are telling them vastly different things.

The nay-sayers stress that beta-blockers carry some risks – notably they can exacerbate asthma and suppress heart beat and blood pressure, especially in patients who have failing hearts.

Dr. Lee Fleisher, an anesthesiologist at Johns Hopkins Medical Institutes in Baltimore, for instance, agrees that heart function should be closely monitored and controlled during and after surgery. But he argues there’s too little data to recommend that beta-blockers be used more routinely in surgery.

Dr. Thomas Graboys, director of the Lown Cardiovascular Center at Boston’s Brigham and Women’s Hospital, puts it more bluntly. If a person is at risk for heart disease, he “should be on beta-blockers whether he’s having surgery or not,” he says. But giving beta-blockers routinely to surgical patients is risky because of the chance that the drugs might overly suppress heart rate and blood pressure.

On the other side, beta-blockers in general “are safe and have been administered . . .to hundreds of thousands of people,” argues Dr. Peter Rock, an anesthesiologist at Washington University in St. Louis, who advocates wider use of the drugs for surgical patients.

The American College of Physicians agrees. In 1997, it recommended that all surgical patients with heart disease or at risk for it take beta-blockers around the time of surgery, unless there is a strong reason not to.

Last year, the journal Anesthesiology threw its weight behind beta-blockers, too, in an editorial that concluded that “the majority of patients with risk factors for coronary artery disease should be treated with at least some type of [ beta] -blocker” at the time of surgery.

The reason is that surgery is a huge stress on the body.

 “Having an operation triggers a cascade of stress hormones,” including adrenalin, which makes the heart beat more strongly and rapidly, says Dr. Daniel Carr, vice chair for anesthesia research at the New England Medical Center. “Even if the person is unaware that his body is being operated upon because of general anesthesia, these primal reflexes are still present.”

And the stress from surgery, particularly on the heart, continues after a patient wakes up. “It’s like being on an exercise treadmill for five days,” says Mangano, “even when pain, a notorious stressor, is well-controlled.”

In fact, peak heart attack risk comes three days after surgery, says Dr. James B. Froehlich, co-director of vascular medicine at the University of Michigan Medical Center in Ann Arbor. That’s when fluids that have leaked from blood vessels into injured tissues seep back into circulation, increasing the workload of the heart.

The adrenalin surge that occurs during surgery also has a lingering effect on platelets, which become stickier and more likely to form clots that can clog coronary arteries. Surgical stress also causes the fatty plaque that lines artery walls to become unstable, which means that the pieces of the plaque can break off and block coronary arteries, even months later.

All of this has persuaded many doctors to lean toward wider use of beta-blockers for surgical patients with heart disease risk. “Even if the effect is half of what Mangano found, it’s still unbelievable,” says Shinbaum, the Beverly anesthesiologist.

Mangano puts it bluntly: “If we demand further studies, it will take three more years, during which time hundreds of thousands of patients will be deprived of an outstanding therapy and might die.”

Dorothy Teixeira isn’t about to argue with that. She had no heart problems during or after her colon surgery, she says. And despite having chemotherapy for her cancer, she says, “I went out New Year’s Eve. I’m doing pretty good, considering.”

What to ask the doctor

Things to talk to ask your doctor about if you have heart disease, or are at risk of it, and are facing noncardiac surgery:

  • Make sure everyone on your team – your internist, your surgeon and your anesthesiologist – know about your heart disease risk and all medications you are taking.

  • Ask how the stress of surgery may affect your heart and whether the risks of surgery outweigh this risk.

  • If you’re already on beta-blockers and any doctor on your team suggests stopping them around the time of surgery, ask why. – If you’re not on beta-blockers, ask if you should be and whether you should start before and continue after surgery.

  • Before you’re discharged, ask how well your heart tolerated the surgery and whether you should take beta-blockers at home.

For more information on the arguments for using beta blockers, you may call the Safe Surgery Hotline, 1-800-700-2617 begin_of_the_skype_highlighting              1-800-700-2617      end_of_the_skype_highlighting, organized by Dr. Dennis T. Mangano at the Ischemia Research and Education Foundation in San Francisco. There is believed to be no comparable site on the other side of the controversy.