Peripheral vascular surgery using targeted beta blockade reduces perioperative cardiac eventrate
de Virgilio C, Yaghoubian A, Nguyen A et al
J Am Coll Surg 2009; 208:14-20
Harbor-UCLA Medical Center, Torrance CA, USA
Preoperative cardiac clearance often includes stress testing in many protocols. There is doubtregarding the value of dipyridamole-thalllium stress testing (the most commonly used test) as apredictor of adverse perioperative cardiac events. The question arises whether there is a subsetof patients who can receive perioperative beta blockade and proceed directly to surgery withoutany stress testing.
“...peripheral vascular surgery and lower extremityamputation can be safely performed without preoperative cardiac testing in lowto intermediate cardiac risk patients, provided universal perioperative [beta]blockade is administered.”
Beta blockade and adverse perioperative cardiac events
Study (n=100)Controls (n=80)
Number received beta blockade10049
Arrhythmia02Myocardial infarction27CHF01Cardiopulmonary arrest01Cardiac death00Composite endpoint28Although the authors submit some fancy statistical analysis that is seriouslyquestionable, the numbers are simple enough for you to be the judge. Keepin mind the worrisome fact that
49 of 80 controls received beta blockade
, astatistic that is snuck in amidst the fine print.
This paper, best described as being one of a "me too, me three ..." genre, reinvents the wheel in an unconvincing manner.From an EBM standpoint, flaws abound. To begin with, the target heart rate was inadequately established in a largenumber. The controls are a mixed bag of case-controls which the authors have clubbed together for comparison. Whileasserting that there is no need for stress testing, only 11 of 80 patients in the control group had a stress test and 49received beta blockade! The authors are comparing apples with a mixed bag of apples and oranges. And, the real zingeris the statement found tucked in the "Composite study end points" section that states: " Among the 24 control patients who did not receive beta blockade, there were 2 cardiac events. Among the 48 patients who did receive beta blockade,there were 6 cardiac events." You don't even need a calculator, leave alone a biostatistician, to see the contradictory, jaw-dropping inference.
The devil is in the details (more on the paper) ...
Dr Arjun Rajagopalan
Evidence levelOverall ratingBias levels
Double blind RCT
Life's tooshort for this
Full of holes
“Just do it”SamplingRandomized controlled trial (RCT)ComparisonProspective cohort study - not randomizedMeasurementCase controlled study
Case series - retrospective
Patients undergoing vascularsurgery or lower limb amputationwith low to intermediate cardiacrisk.
Universal "targeted" beta blockageand subsequent surgery withoutany stress testing
Cardiac events occurring within 30days of the surgery or in the samehospitalization.
A matched group of controls,selected from a retrospectivecohort of patients from 2001-03.
3 April 2009
Evidence-based Medicine for Surgeons