Effect of Atenolol on Mortality and Cardiovascular Morbidity after Noncardiac Surgery

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Abstract
Dr. Mangano and other investigators in the Multicenter Study of Perioperative Ischemia Research Group (Dec. 5 issue)1 have failed to report directly the outcome of the eight patients in the placebo group who were taking beta-blockers preoperatively. There were 12 deaths from cardiac causes in the placebo group. If all eight patients who were taking beta-blockers preoperatively died from cardiac events, then what the authors have really found is that the sudden perioperative withdrawal of beta-blockers is deleterious. This is quite possible, given the well-supported position, which the authors promote, that the effects of tachycardia and hypertension are deleterious. The fact that many of the patients in the atenolol group were also receiving beta-blockers does not compensate for this type of bias, since those patients never underwent short-term perioperative withdrawal of the beta-blockers but, rather, were maintained on this therapy throughout hospitalization by virtue of receiving the drug rather than the placebo.