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Tuesday, April 05, 2011
Peri-operative beta blockade: atenolol or metoprolol
What is different about medical care now compared to when my father was practicing medicine more than 50 years ago? Today, the art of medicine, though still a component of patient care, is often trumped by scientific data that has resulted in practice protocols that standardize therapy for very good reason, i.e., improved patient outcomes! Cardiovascular morbidity and mortality rates associated with anesthesia and surgery are major concerns that have benefited from standardization of care as demonstrated by the Perioperative Cardiac Risk Reduction Therapy (PCRRT) Protocol and Surgical Care Improvement Project. Joined by guides for reduction of antibiotic use and surgical site infection as well as venous thrombosis prophylaxis, beta-blockade is a universally accepted approach1,2,3,4 to the reduction of ischemic cardiac complications associated with anesthesia and surgery. Anesthesiology has published data5 that clearly supports the use of beta-blockade because of the increase in mortality that results from withdrawing this therapy.

In the April issue of Anesthesiology,6 the guideline is further refined by an epidemiologic study characterizing the relative benefit of one beta-blocker (atenolol) compared to another (metoprolol). Review of surgical patients between1996 and 2008 at one institution evaluated patients who were not on beta-blockers prior to surgery and who received at least one dose after surgery compared to patients who were on beta-blockers prior to surgery and who received at least one dose after surgery, specifically documenting whether the beta-blocker used was atenolol (1,011 patients) or metoprolol (2,776 patients). This study demonstrated that not only did beta-blocker therapy generally reduce cardiovascular morbidity, but 30-day mortality (atenolol 1% versus metoprolol 3%, p < 0.0008) and 1-year mortality (atenolol 7% versus metoprolol 13%, p < 0.0001) differed between the two beta-blockers.

So, what does an anesthesiologist do with these conclusions? Switch to atenolol when caring for similar patients? Perhaps there are confounding factors that leave the arrived at conclusions suspect. Maybe differences in mortality observed between metoprolol and atenolol really signify an inability to eliminate bias introduced by an epidemiologic study that could not factor out that metoprolol patients were sicker in the first place. The authors wisely suggest that their results could “…be viewed as a hypothesis-generating study, best followed by a randomized controlled trial…” (There is a challenge for some of you!)

Perioperative beta-blockade in high-risk patients has been a standard of care since 1996.2 The present study points out that our understanding of the benefit to patients is multifactorial and in need of further scrutiny. How do you employ beta-blockade in your anesthesia patient care? Which beta-blocker do you use? Tell us what you have observed as you treat your patients with beta-blockers.

References
1. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ, Leppo JA, Ryan T, Schlant RC, Winters WL,Jr, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Jacobs AK, Hiratzka LF, Russell RO, Smith SC,Jr: ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery--Executive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg 2002; 94: 1052-64
2. Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, Leppo JA, Ryan T, Schlant RC, Spencer WH,3rd, Spittell JA,Jr, Twiss RD, Ritchie JL, Cheitlin MD, Gardner TJ, Garson A,Jr, Lewis RP, Gibbons RJ, O'Rourke RA, Ryan TJ: Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery. Circulation 1996; 93: 1278-317
3. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC,Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B, American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology: ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology. Circulation 2006; 113: 2662-74
4. Fleischmann KE, Beckman JA, Buller CE, Calkins H, Fleisher LA, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Robb JF, Valentine RJ: 2009 ACCF/AHA focused update on perioperative beta blockade: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation 2009; 120: 2123-51
5. Wallace AW, Au S, Cason BA: Association of the pattern of use of perioperative beta-blockade and postoperative mortality. Anesthesiology 2010; 113: 794-805.
6. Wallace AW, Au S, Cason BA: Perioperative beta-Blockade: Atenolol Is Associated with Reduced Mortality When Compared to Metoprolol. Anesthesiology 2011; 114: 824-36

Posted by Alan Jay Schwartz, M.D.,MSEd
Alan Jay Schwartz
About the Author

J. Lance Lichtor, M.D
J. Lance Lichtor, M.D. is a professor of anesthesiology and pediatrics at The University of Massachusetts Medical School. He is the web editor and an associate editor for Anesthesiology.

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