Thursday, November 08, 2007

Peri-operative beta-blockers- A quality indicator or a bad idea?

The November 9,2007 edition of Med Page Today features a report of a paper given at the AHA meeting that casts serious doubt on a major recommendation of the AHA and a widely used "quality" measure.

There have been rumblings for some time that the rush to use beta-blockers to reduce cardio-vascular mortality and morbidity during and after surgery was ill advised.The rumblers now have a more convincing argument.

Dr. P.J.Devereaux reported the results of the POISE trial, which was an drug company randomized trial of over 8,000 patients, aged 45 or over undergoing noncardiac surgery and who had or were at risk for arteriosclerotic disease. The treatment arm received metoprolol 2 to 4 hours pre-op and had the medication continued for one month after surgery.

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 %),

I have suggested before that quality measures may be hazardous to your health in regard to the four hour pneumonia rule. This may be an even more glaring example. I submit that in the rush to infuse "quality" into medical practice we may have codified a practice, that may generate more harm than good, (I am sure folks will argue over that) based on far less than convincing evidence.

1 comment:

Jon M Baker MD FACS said...

I agree completely.
I am a General and Thoracic surgeon at the VA, and the VA has a rule that we must give perioperaive beta blockers to all patients 18+ years old. The old way out if for the patient to refuse. Which I often recommend they do refuse to take it. Beta blockers decrease spanchnic perfusion the gut which is bad for a new bowel anastamosis, we have seen more leaks since beta blockers were instituted. On rounds when we see sinus tachycardia instead of finding the cause and fixing it, the Chief of surgery increase the dose of beta blocker to get that heart rate down. We use to think. This beta blocker rule is stupid and dangerous.