California Society of Anesthesiologists Bulletin Spring/Summer 2014 - (Page 25)

The Perioperative Use of Beta Blockers: The Devil Is in the Details By Lee A. Fleisher, MD, Robert D. Dripps Professor and Chair of Anesthesiology, Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania I n this issue of the CSA Bulletin, Dr. Karen Sibert authors a provocative piece on the evidence behind performance measures. With regard to the SCIP beta blocker measure that she discusses, it is important to understand that the measure was narrowly written to determine if patients who are having surgery and who were on beta blocker therapy prior to admission received a beta blocker during the perioperative period. She does appropriately suggest that the ideal management strategy to improve outcome should include management of perioperative hemodynamics associated with the occurrence of perioperative cardiac morbidity and mortality. However, in discussing the beta blocker measure, Dr. Sibert focuses on the current controversy regarding initiation of beta blockers, which is entirely separate from the SCIP measure that only addresses continuation of these agents for patients currently taking them. She is correct that there are no randomized data to suggest that continuation improves outcome, but a number of older studies, as well as some more recent data, do support this recommendation. The concerns regarding the increased risk of stroke identified in the POISE trial were considered by the American Heart Association/American College of Cardiology Foundation (AHA/ACCF) when they published their update in 2009: Class I: Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers for treatment of conditions with ACCF/ AHA Class I guideline indications for the drugs (Level of Evidence: C). 1 The data from the DECREASE trials by Poldermans were not relevant to this recommendation but did lead to a change in the U.S. guidelines, downgrading the recommendation - which was never a SCIP measure - that these agents be initiated perioperatively. Moreover, the story by Larry Husten in Forbes was based upon a paper that was retracted (of note, none of the DECREASE trials have been retracted) by the journal and led to an editorial in the European Heart Journal. In that editorial, Professors Thomas Lüscher, Bernard Gersh, Ulf Landmesser and Frank Ruschitzka highlight, among other points, that "jumping to conclusions may attract attention, but it appears inappropriate for physicians and journalists alike, and may confuse patients, if the scientific basis is still uncertain, as it currently is."2 (continued) Spring/Summer 2014 | 25 

Table of Contents for the Digital Edition of California Society of Anesthesiologists Bulletin Spring/Summer 2014

Editor's Notes
President's Page
Peering Over the Ether Screen
The Dark Side of Quality Reilluminated and Reimagined
The Perioperative Use of Beta Blockers
ASA Director's Report
Physician Well-Being
Upcoming CSA Anesthesia Seminars
Our Stories
From the Executive Director
Our Stories
Practice Alert
On Your Behalf: Legislative and Practice Affairs
CSA Political Alert
Taking the CSA Grassroots and GASPAC Program from 'Good' to 'Great'
CSA Winter Anesthesia Seminar 2014: Midwinter Educational Interlude
California and National News
News from the Districts

California Society of Anesthesiologists Bulletin Spring/Summer 2014

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