Saturday, October 24, 2009

The resurgence of perioperative betablockers

Exciting news for all the hospitalists and perioperative medicine specialists. A large study done between 1996 and 2008 by Dr. Wallace, an anesthesiologist from the VA Hospital (UCSF)
(http://www.cardiacengineering.com/bbac/) showed survival benefits of perioperative beta blockers for patients with cardiovascular risk.

He uses a protocol called PCRRT that stands for Perioperative Cardiac Risk Reduction Therapy and can be accessed at http://www.cardiacengineering.com/bbac/PCRRT.pdf.

The protocol uses up-titrating dose of oral atenolol if the HR is >60x' or SBP > 120mmHg. They use iv metoprolol on the day of surgery and until the patient is able to take po, and then resume atenolol postoperatively at a dose of 100 mg once a day for 7 days. They advocate the indefinite use of betablockers in patients with CAD or PAD.

Fascinating is the fact that in the patients that betablockers were contraindicated, they used the alpha 2 agonist agent clonidine at a dose of 0.2 mg the night before surgery, a clonidine patch at a dose of 0.2 mg/24h and an additional oral dose of 0.2 mg in the AM of surgery.

The mortality at 30 days and 1 year was:
- Addition of betablocker:
30 days - O.R. 0.52 (95%CI, 0.33 - 0.83; P =.0055) ---> Reduction of almost 50%
1 year - O.R. 0.64 (95% CI, 0.51 - 0.79; P =.0001) ----> Reduction of almost 40%

- Continuation of previous betablocker:
30 days - 0.68 (95% CI, 0.47 - 0.98; P =.037) ---> Reduction of 32%
1 year - 0.82 (95% CI, 0.67 - 1.0; P =.05) ---> Reduction of almost 20%

- Withdrawal of previous betablocker:
30 days - increase in mortality 4-fold (P < .0001) 1 year - doubled mortality (P > .0001)

This information is very exciting, and supports the value of perioperative betablockers. The POISE trial brought a lot of noise in the perioperative medicine world; they used a very supraphysiologic dose of metoprolol in a very rapid fashion with no titration. This is a major caveat considered by the detractors of its results, mainly Dr. Poldermans.

The recently published European Society of Cardiology guidelines for Perioperative cardiac risk reduction in non-cardiac surgery (which were lead by Dr. Poldermans), advocate the use of perioperative betablockers in patients with 2 or more RCRI factors.

We should continue being careful in identifying this subset of patients. However, patients with stable systolic heart failure and coronary artery disease by themselves, benefit from the use of betablockers, regardless of the presence of other risk factors, although most likely they will in fact, have them given the common pathophysiologic ground - atherosclerosis -. The recent results of DECREASE group showed the benefits of adding fluvastatin perioperatively to patients undergoing vascular surgery (http://content.nejm.org/cgi/content/short/361/10/980).

I liked very much Dr. Wallace webpage (link above) and I think this large VA study will bring a significant backup to the use of betablockers in the perioperative setting. The use of clonidine was very refreshing. The idea is to control the heart rate - I wonder what result will a trial using calcium channel blockers or digoxin could bring . Comparing diltiazem or verapamil versus placebo versus betablockers versus clonidine and have subgroups with and without statins - I think the results will be very interesting. At the very end of the road, we want to decrease heart rate and perioperative oxygen consumption after induction of anesthesia.

I would love to see a discussion between Dr. Wallace, Dr. Devereaux and Dr. Poldermans. It would be very fascinating!

Reference can be accessed here. I look forward for a published article in a strong impact factor journal (JACC, Circulation or Anesthesia and Analgesia).

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