Beta-Blockers: Choosing the Right Patient

In a retrospective evaluation of over 130 thousand patients at one of 104 Veterans Health Administration hospitals undergoing non-cardiac surgery between 2005 and 2010, peri-operative use of beta-blockers was associated with lower risk of mortality and cardiovascular events.  Notably when looking at risk reduction among subgroups based on RCRI criteria, significant reductions in risk were present among those with RCRI ≥ 2.

There was no difference in rates of stroke in the matched cohort between those receiving and those not receiving beta-blockers.

Additionally, they noted a decrease in overall use of peri-operative beta-blockers from 44% in 2005 to 36% in 2010, which could be attributed to the findings from the 2008 POISE trial.

Review by Rachel Thompson MD FHM

Link to JAMA Abstract

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Is continuing SSRIs before surgery associated with an increased bleeding and death?

A recent study in JAMA Internal Medicine using hospital billing data to conduct an observational cohort study evaluated the association between perioperative use of SSRIs and various health outcomes. SSRI use compared with nonuse was associated with an increased risk of bleeding (incidence of 2.7 v 2.5%). However, this association was not robust to various sensitivity analyses, such as comparing SSRI use with the use of other antidepressants. Other observational studies in nonsurgical patients have identified similar associations between SSRI use and bleeding, although these studies had similar limitations. Currently, there remains uncertainty about whether SSRI use is associated with an increased risk of perioperative bleeding, and the absolute magnitude of such risks are likely to be small if they indeed exist.

There is no clear clinical action given the current level of evidence.

Reviewed by James Floyd MD MS

Link to abstract in JAMA Internal Medicine

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Do Statins Really Measure Up?

Additional information this year has led to questions about the validity of the primary works supporting statin initiation preoperatively.  There is physiologic rationale to not withdrawal statins in the perioperative period, however as a practice there is insufficient evidence at this time to start a statin unless otherwise indicated.

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Perioperative Statins Reduce Morbidity

February 20, 2012

This February, a group from Michigan presented a synthesized view on statin use in the preoperative period. The authors reviewed 15 prospective randomized controlled studies of statin initiation. Reported clinical outcomes included  atrial fibrillation, myocardial infarction, length of stay and death.

In this meta-analysis myocardial infarction and length of stay were noted to be significantly reduced among patients initiated on statins. There was a non-significant trend toward reduced mortality as well. Notably, atrial fibrillation was also reduced among the cardiac surgery subset with a number needed to treat of only 6.

The authors suggest that broader use of statins in the preoperative period be considered; thought consensus data is lacking on the best timing or dosing.

Link to abstract in Archives of Surgery

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Beware Beta-Blocker Withdrawal

January 16, 2012

In a look at over 8000 patients in the State of Washington, researchers found that failure to continue beta-blocker treatment perioperatively among patients having general surgery (bariatric and colon surgeries) was associated with nearly two-fold the risk of 90 day combined adverse effects (odds ratio, 1.97; 95% CI, 1.19-3.26). Patients with higher cardiac risk had even greater associations. Adverse effects included death and cardiac complications. This risk continued to be elevated one year postoperatively.

Beta-blocker continuation is a quality measure for all surgeries. This research has provided the largest support for this quality measure and extends its importance to non-cardiac and non-vascular surgical populations.

Link to abstract in Archives of Surgery

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Perioperative Myocardial Infarction

Tuesday, April 19, 2011

In the April issue of the Annals of Internal Medicine PJ Devereaux and colleagues provided the largest descriptive cohort of perioperative myocardial infarction (MI) to date; exploring data from the perioperative course of 8531 patients enrolled in the POISE trial (Lancet 2008).

Disturbingly, 35% of all perioperative MI were without symptoms. The majority of all MIs occurred within 48 hours of surgery. 30 day mortality among those with MI (symptomatic or not) was 4 fold that of those without. Notably, the patient population in this study included patients with some elevated degree of cardiac risk.  Thus, in our patients undergoing intermediate to high risk surgeries who have underlying coronary risk factors, it may be reasonable to increase postoperative monitoring to include at minimum a follow up EKG compared to preoperative EKG and possibly postoperative cardiac enzymes.

Link to abstract in Annals of Internal Medicine

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RABBIT2 Surgery

Monday, February 28, 2011

The February issue of Diabetes Care carried the awaited publication of RABBIT2 Surgery which compares the efficacy and safety of basal/bolus insulin with sliding scale insulin in the general surgical non-ICU patient.

In this multicenter randomized controlled trial, subjects received either scheduled basal/bolus insulin (n104) from a weight based calculation or sliding scale insulin alone (n107). The average glucose on day one for basal/bolus was 145 ± 32 compared to 172 ± 47 (p<0.001). Notably among subjects in the basal/bolus group glycemic control was achieved earlier and better maintained. In addition, significantly fewer complications were seen in the basal/bolus group (OR 3.39; 95% CI 1.5-7.95). No mortality benefit was seen.

Euglycemia for surgical inpatients, even non-ICU, is demonstrated to correlate with outcomes. Moreover, this study supports the practice of using a physiologic based methods for insulin administration–basal/bolus–rather than the reactive sliding scale.

Link to abstract in Diabetes Care

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