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The Beta Blocker and Clonidine Protocol

Lesson 2
Lesson 2 - Epidemiology

7. Dennis Mangano

Take it from HippocratesNow, Mangano. Mangano did a fundamental study as well. Dr. Mangano studied 474 patients at the VA undergoing non-cardiac surgery and found that old sick people did poorly. More specifically he found that patients with coronary artery disease, peripheral vascular disease, or two risk factors for coronary artery disease: age 65 or older, hypertension, diabetes, smoking, elevated cholesterol had more events. More importantly he found that 41 percent of them had an episode of myocardial ischemia on Holter monitoring taken in the perioperative week. Now this 40% rate may seem a bit high, but it is one millimeter, for one minute. It is not the myocardial ischemia where the patient calls the nurse with chest pain. Only 5% of this ischemia was detected by clinical staff.

If only 5% is detected by clinical staff, is it important? YES! A single one minute episode of myocardial ischemia raised the risk of cardiac death, myocardial infarction, unstable angina, congestive heart failure, or ventricular tachycardia by a factor of 9 fold. Yikes! A single one minute episode of myocardial ischemia increases the risk of an ischemic event 9 fold.

Mangano et. al. NEJM 1990

bullet Postoperative myocardial ischemia occurred in 41 percent
bullet Associated with a 2.8-fold increase in the odds of all adverse cardiac outcomes (95 percent confidence interval, 1.6 to 4.9; P less than 0.0002)
9.2-fold increase in the odds of an ischemic event (95 percent confidence interval, 2.0 to 42.0; P less than 0.004).
bullet CONCLUSIONS. In high-risk patients undergoing non-cardiac surgery, early postoperative myocardial ischemia is an important correlate of adverse cardiac outcomes.

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