Forecasting the Impact of a Clinical Practice Guideline for Perioperative β-Blockers to Reduce Cardiovascular Morbidity and Mortality

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Abstract
PERIOPERATIVE myocardial ischemia and myocardial infarction are important causes of morbidity and mortality among patients undergoing major noncardiac surgery.1-4 At highest risk are the estimated 7 to 8 million patients with multiple cardiac risk factors or with established coronary artery disease (CAD).1,3 By slowing the heart rate, decreasing blood pressure, and moderating hemodynamic stress responses, β-blockers reduce the incidence of perioperative myocardial ischemia.5-7 In a recent Veterans Affairs hospital randomized controlled trial,8 the perioperative administration of the β-blocker atenolol to high-risk patients resulted in significant reductions in mortality and cardiovascular complications beginning at 6 months and extending to 2 years following surgery. Following this report, the American College of Physicians9 recommended that β-blockers be considered for perioperative use in all high-risk patients undergoing major noncardiac surgery. More recently, bisoprolol was shown to reduce mortality when administered perioperatively to high-risk patients undergoing vascular surgery.10 Although we are not aware of any studies documenting how often perioperative β-blockers are used in routine practice, if practice patterns in patients with myocardial infarction can serve as a guide, it is quite possible that these medications are being underused.11,12