Con: β-blockers should not be used in all patients undergoing vascular surgery

T IS WELL ESTABLISHED that control of heart rate is an important perioperative management goal and 13-blockers are an effective means to achieve it.The use of 13-blockers has been advocated for more than a decade in high-risk noncardiac surgical patients, based on retrospective series, small clinical trials, and experience in the general cardiologic population.Mangano et al 1,2 recently published two articles reporting the beneficial effects of routine perioperative atenolol administration in a randomized clinical trial.However, recent trends in medical practice demand an evidence-based approach before a practice or intervention is considered standard of care.3 The question remains regarding whether the recent trial should be considered sufficient evidence to define the current standard of care.Numerous studies evaluated the relationship between 13-blockers and cardiac morbidity.Slogoff and Keats 4,5 performed the first such study, in which the incidence of perioperative myocardial ischemia in patients undergoing coronary artery bypass grafting was less in those who received 13-blockade versus those who did not; however, the decision to provide [3blockade was based on prior use.Pasternack et al6 also evaluated the incidence of perioperafive myocardial ischemia in patients administered 13-blockers compared with a cohort of untreated patients and found a lower incidence of myocardial ischemia, but no difference in myocardial infarction.Stone et al 7 randomized patients with hypertension to receive one of three 13-blockers or placebo.They also showed a significantly lower incidence of ischemia, but no difference in outcome.More recently, Mangano et al 1 performed a randomized, prospective, placebo-controlled trial of atenolol versus placebo in patients at high risk for coronary artery disease undergoing noncardiac surgery.The investigators reported a significant decrease in mortality at 6 months postsurgery that persisted for up to 2 years.Importantly, no difference in perioperative outcome was noted, although the atenolol group had significantly fewer episodes of myocardial ischemia.2Despite the significant long-term results and rigorous study design, the question remains regarding the generalizability of the results.In interpreting any randomized clinical trial and its applicability to an individual patient, it is important to look at both biological and epidemiologic issues.It is well established that patients who have sustained a myocardial infarction benefit from both short-and long-term 13-blocker therapy, as shown in large-scale studies such as the First International Study of Infarct Survival.a It is also well established that 13-blocker therapy is underused in patients with coronary artery disease.