Blocking heart trouble after surgery

CHAPEL HILL -- There's been news lately about the number of orthopaedic surgical procedures, especially total knee replacements, performed at smaller community regional hospitals. Several months ago, a man died shortly after this knee surgery at a regional hospital from a cardiac complication, presumably a fatal heart attack. Investigators from the Center for Medicare and Medicaid Services disclosed numerous problems at the hospital that might have contributed to this tragic complication.

However, total knee replacement surgery is usually a safe and effective treatment for severe pain and difficulty walking due to arthritis of the knee. Over 200,000 knee replacements are performed annually in the United States, and the number of people who may need this procedure could be more than 2 million by 2030.

There are always some risks to the patient when major elective surgery is performed. Two studies, each of over 3,000 patients who had total knee replacement surgery in Philadelphia and Texas, reported that death after surgery, although less than 1 percent of the patients, is related twice as frequently to a heart attack as to a blood clot in the lungs.

It's been proven that the use of a certain heart medication, a Beta-blocker, can decrease the number and severity of heart-related complications after general and vascular surgery. However, the use of this type of medication (such as atenolol or metoprolol) before and after total knee replacement surgery has not been frequently reported or emphasized.

In 2003, in response to a review that disclosed four deaths from heart attacks after elective orthopaedic surgery, UNC Hospitals introduced an institution-wide Beta-blocker prophylaxis protocol. The surgeons of UNC Orthopaedics have embraced this protocol, which evaluates a patient's risk for a heart attack after knee replacement surgery based on age and the presence of other illnesses.

In a recent study of almost 300 knee replacement surgeries at UNC, I reported that almost three-fourths of patients were given a Beta-blocker medication before and after surgery. The results of this study were gratifying. There were no deaths in the first 90 days after total knee replacement, and only two patients (0.7 percent) had nonfatal heart attacks.

The study concluded that all total knee replacement patients should be evaluated before surgery using this protocol to determine if Beta-blocker medication should be given. There are slight potential risks with this medication. The complications of infection and pneumonia can still occur.

Patients who are considering total knee replacement surgery for arthritis should not be unduly fearful of a fatal post-operative complication, even at a regional hospital. However, if appropriate, careful evaluation before surgery by an internal medicine or cardiology specialist should be considered. Patients might also now ask their orthopaedic surgeon and anesthesiologist if a Beta-blocker medication should be given before and after this surgery.

(Dr. Paul Lachiewicz is a professor and attending surgeon in the Department of Orthopaedics at the UNC School of Medicine-UNC Hospitals.)