LANdiolol to Avoid TAchycardia in Patients at Risk for Cardiovascular Events Undergoing Major Non-cardiac Surgery

Inclusion Criteria:

• Patients undergoing elective non-cardiac surgery defined as intermediate orhigh-risk by the 2022 european society of cardiology (ESC) guidelines

• surgery performed under general anesthesia;

• expected length of hospital stay ≥ 24 hours;

• age ≥ 45 years;

• at least two of the following risk factors:

• age ≥ 75 years

• arterial hypertension;

• ischemic heart disease (history of myocardial infarction or positive exercisetest, current complaint of chest pain considered to be secondary to myocardialischemia, use of nitrates, pathological Q waves, prior coronaryrevascularization);

• history of congestive heart failure;

• history of cerebrovascular disease;

• peripheral artery disease;

• diabetes mellitus;

• GFR ≤ 59 ml/min pro 1.73 m2;

• pre-operative NTproBNP > 200 pg/ml;

• excessive sympathetic outflow as proven by exercise testing:

• impaired heart rate recovery (≤ 12 bpm within 1 minute after cessation ofexercise); OR

• exaggerated heart rate response (≥ 12 bpm after 3 minutes of unloadedpedalling);

Exclusion Criteria:

• unable to consent or follow study procedures;

• absolute contraindications for exercise testing;

• pregnancy or intention to become pregnant;

• active cardiac conditions (such as unstable coronary syndromes, decompensated heartfailure, significant arrhythmias, severe valvular disease);

• urgent / emergency surgery;

• already on β-blocker (within the last 30 days prior to recruitment);

• contraindication for β-blocker therapy (bradycardia (HR < 55 bpm), hypotension (systolic blood pressure < 100 mmHg), severe peripheral vascular disease, severeasthma, allergy, higher-degree atrioventricular block);

• severe preoperative anaemia (haemoglobin < 100 g/L) unless there is a plan set upand followed for correction prior to surgery;

• planned intermediate care or intensive care admission;

• prior enrolment in this trial.