POISE trial seems poised to change perioperative guidelines for beta blocker use

According to the trial, perioperative beta blockers may decrease the incidence of myocardial infarction but the survival benefits are offset by the increase in strokes.

The study principal investigator, Dr Philip J Devereaux (McMaster University, Hamilton, ON), said he was unable to determine who would be at risk and who would benefit from perioperative beta-blocker use at this stage, but added, "I certainly would not recommend it to my mother."

There was a decrease in nonfatal MI ( 3.6% versus 5.1%) but there were more strokes in the beta-blocker group ( 1.0% versus 0.5%) and a greater total mortality in the treatment arm (3.1 % versus 2.3 %).

Our current practice at Cleveland Clinic is to start long-acting beta-blockers 2-4 weeks prior to noncardiac surgery in patients with Revised Cardiac Risk Index (RCRI) score higher than 2-3 and continue for 2-4 weeks after surgery. We may need to reevaluate practice in the light of the new data from the POISE trial.

Andy Auerbach of UCSF describes how he would change his prescribing pattern regarding perioperative beta-blockers in a post on Wachter's World:

"How is my practice today different than it was before last week? I’ll continue the beta blockers for my patient who was on them previously, I’m more likely to recommend starting beta blockers a couple of weeks before surgery in high risk patients, and I’m less likely to prescribe perioperative beta blockers in the intermediate risk pre-op patient (in whom I might now perform some testing to better define the true risk). I’m also less likely to use a high dose to start, or to titrate up the beta blocker dose for tachycardia unless I am certain that I’m not treating tachycardia due to hypovolemia, bleeding, or infection first."

What other medications can be used to decrease cardiovascular risk in the perioperative period?

Statins looks promising. Researchers from Cleveland Clinic just presented an abstract on the topic at the AHA meeting where the POISE trial results were announced. The retrospective study included more than 5,200 patients who underwent coronary bypass (CABG). Treatment with statins after CABG seemed to reduces a stroke risk.

One of the co-authors of the study is Dr. Peter Zimbwa with whom I am lucky to share an office here at Cleveland Clinic. Peter is a remarkable physician and researcher, and his resume is as impressive as his titles -- he has MD, MSc, PhD, MRCP, DTM (just to name a few).

Dr. R.W. Donnell has commented on the projected benefits of statin use in the perioperative period: "look for statins to emerge as the “next beta blockers” for perioperative treatment in the coming years."

References:
POISEd to change the guidelines on perioperative use of beta blockers? The Heart.org.
AHA: Surgery with Beta-Blockers Onboard May Be Risky. MedPage Today.
Peri-operative beta-blockers- A quality indicator or a bad idea? Retired doc's thoughts.
Peri-operative Beta-blockers: Much room for evidence still exists! BMJ.
Perioperative beta blockers may not benefit patients with diabetes (if not used properly)
Case 2: Does this patient need a beta-blocker?
Continue statins as seamlessly as possible before and after vascular surgery. Notes from Dr. RW.
Perioperative beta blockers: not so fast! Notes from Dr. RW.
Three Remarkable Articles Last Week. Wachter's World, 11/2007.
Perioperative Beta Blockers, Redux. Wachter's World, 11/2007.
Image source: OpenClipArt.org, public domain.

Updated 11/16/2007

2 comments:

  1. The results of this large trial should give all perioperative docs pause to carefully examine any mandated care under the guise of "best practice", or SCIP.

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  2. I wonder if results of POISE would be different if they had started it earlier(say 2 weeks prior to surgery) and not so close to surgery?

    Also the risk (stroke, NNH of 200) is less than the benefit of nonfatal MI (NNT 67). This may be acceptable to patients. And it will be interesting to see when the paper comes out if higher risk (cardiac) pts have even a better NNT/NNH ratio thus confirming with Lindenauer data (benefits of beta-blockers based on Lee criteria)

    Should we act on this (withhold beta blockers) study or wait and see?

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