Con: Beta-blockers are indicated for all adults at increased risk undergoing noncardiac surgery.

Martin J. London, MD Although anesthesiologists have long recognized the value of using -adrenergic receptor blocking drugs perioperatively to attenuate adrenergic “stressors,” it is only recently that other specialties have rallied around “perioperative -blockade” (PBB) (1). This enthusiasm is linked to the publication of two seminal but controversial reports in the New England Journal of Medicine (2–3) and the tentative recommendation for PBB by the American College of Physicians in 1997 (4). Interest in PBB has grown to a “fevered pitch” with its designation as a top tier “safety practice” by the Agency for Healthcare Research and Quality’s report (5) and has become “highly desirable” in the eyes of clinicians interested in optimizing patient outcome, hospital administrators eager to enhance their hospitals status as a provider of “safe care,” and, more recently, by administrative organizations developing performance measures for benchmarking care and reducing costs. From the onset, however, there was skepticism about PBB by clinicians and researchers trained in classical epidemiologic techniques for evaluating efficacy (e.g., results in a highly controlled setting such as the randomized clinical trial with strict inclusion and exclusion criteria) and effectiveness (e.g., results in the larger universe of clinical practice) (6). Although efficacy (either perioperative or long-term) has been challenged by a few outspoken critics (supported in part by 2 meta-analyses), (7–10) this debate focuses on the evidence that PBB should be routinely administered to all “at-risk patients” and excludes patients already receiving -blockers or those with clear-cut indications for this therapy regardless of surgery (11). “At-risk” patients are usually considered to belong to either of 2 categories: 1) those undergoing high-risk vascular surgery with no evidence of coronary artery disease (CAD) or with stable CAD but without easily inducible ischemia, and 2) those undergoing nonvascular procedures with comorbidities predictive of CAD identified with traditional risk factors (advanced age, high total and HDL cholesterol, elevated blood pressure, cigarette smoking, family history of premature CAD, and diabetes mellitus). Although vascular surgery is recognized as producing the greatest percentage of perioperative adverse cardiac events, the latter group of patients undergoing noncardiac surgery is numerically much larger and thus, in many respects, of greatest interest. Central to this debate are several linked questions: Just how large a problem is cardiac morbidity and mortality in patients without overt CAD (and in what types of surgery)? Do risk factors (or even overt CAD) influence short-term or longer-term (e.g., 1–2 yr) “intermediate” outcome after surgery? What does the current literature of PBB report? With regards to the magnitude of the problem, the literature on the epidemiology of perioperative myocardial infarction (PMI) is derived primarily from investigations of patients with known prior MI and those undergoing vascular surgery (12). Both groups are recognized to have substantially higher risk over the general surgical population. Definitive reports of increased risk for PMI in patients with risk factors alone undergoing nonvascular surgery are lacking. Although accumulating evidence suggests that even low-grade postoperative “troponin leakage” has adverse implications for outcome for up to a year From the Department of Clinical Anesthesia, University of California, San Francisco, San Francisco, California. Accepted for publication May 23, 2006. Address correspondence and reprint requests to Martin J. London, MD, Anesthesia (129), Veterans Affairs Medical Center, 4150 Clement St., San Francisco, CA 94121. Address e-mail to londonm@ anesthesia.ucsf. edu. Copyright © 2006 International Anesthesia Research Society DOI: 10.1213/01.ane. 0000231830.13665. 05