Proceed with Caution: Beta-Blockers in CEA

Use of beta-blockers in the perioperative period has served since 2010 as a key government quality indicator for patients undergoing surgery.

Protocols established by the National Surgical Care Improvement Project (SCIP) encourage the use of beta-blockers during the perioperative period. And yet optimal use of these agents in vascular procedures is far from established – with many surgeons and physicians concerned that the SCIP protocols have resulted in their overuse.

“Our ubiquitous use of these drugs is probably harming people, especially those on higher doses,” said Dr. Michael Stoner of University of Rochester (New York) Medical Center.

For one procedure in particular – carotid endarterectomy – beta-blocker use has been shown to be especially problematic. People with atherosclerosis represent a vulnerable population to begin with, and CEA comes with a high potential for hemodynamic instability in the perioperative period, Dr. Stoner said. Moreover, studies used to establish the national beta-blocker protocols enrolled relatively few CEA patients.

In his presentation Wednesday on beta-blockers and CEA, Dr. Stoner will focus on results from his research group’s provocative 2014 study that looked at records from over 5,500 patients undergoing CEA, identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Of these, more than half were on beta-blockers prior to surgery.

The investigators found beta-blocker use associated with twice the odds of cardiac events, compared with patients not on beta-blockers (odds ratio, 1.97, confidence interval, 1.20-3.25, P = .01) and twice the odds of death (OR 2.01, CI: 1.01-4.01, P = .047), even after controlling for confounders.

Now, Dr. Stoner and colleagues are seeking to validate these findings in a prospective study of CEA patients using the Vascular Quality Initiative database. This will help determine, Dr. Stoner said, whether patient selection or a true beta-blocker effect was responsible for what was seen in the prior study.  
“We have to go back and prospectively look at this and ask are we over beta-blocking – and this is just one surgery,” he said.

Dr. Stoner said he thinks the keys to good management may lie in the dosing and timing of these agents, both of which need to be carefully investigated.

“The medical management of patients having surgery for atherosclerosis is still understudied,” he said. “To really understand it, you probably need a large-scale prospective registry,” he said, with tens of thousands of patients. “There are just so many medications, and the problem is most of the registries don’t have granularity as to the dosing and the timing.”

Dr. Stoner said that it’s likely a subset of patients will benefit from continued beta-blocker use while another subset will not. It is possible that patients on anti-hypertensive agents that promote hemodynamic instability, such as ACE inhibitors, could be at higher risk and may require a more careful approach.

In the meantime, he said, it is possible to adopt a more cautious and flexible approach to beta-blocker use institution-wide, as the University of Rochester Medical Center is now doing. How to implement this approach will be a main focus of Dr. Stoner’s talk.

Beta-blocker use should not be approached as a yes-or-no question, he said, as their optimal use requires more than checking a box as a protocol.

“On the chart we try to document beta-blocker use carefully,” Dr. Stoner said. “We don’t overuse beta-blockers for SCIP prophylaxis reasons. We won’t start patients on a beta-blocker if they weren’t previously on one, and we try to lower the dosage with patients on higher doses.”

The SCIP measures, while promoting beta-blockers in surgery, do not mandate them. “There’s enough flexibility in the guidelines that centers that can adapt care processes like we did in our institution, that are not being overly aggressive with them and documenting carefully, they’ll be okay,” Dr. Stoner said. “But I worry that when these guidelines came out it pushed people toward overuse of beta-blockers.”

Session 31: How Should Beta-Blockers be Used in Vascular Patients Undergoing Procedures: Use and Overuse Can Harm Patients and Their Use Should Not be a Quality Metric

Wednesday, 6:57 a.m. – 7:03 p.m.

Grand Ballroom West, 3rd Floor

Use of beta-blockers in the perioperative period has served since 2010 as a key government quality indicator for patients undergoing surgery.

Protocols established by the National Surgical Care Improvement Project (SCIP) encourage the use of beta-blockers during the perioperative period. And yet optimal use of these agents in vascular procedures is far from established – with many surgeons and physicians concerned that the SCIP protocols have resulted in their overuse.

“Our ubiquitous use of these drugs is probably harming people, especially those on higher doses,” said Dr. Michael Stoner of University of Rochester (New York) Medical Center.

For one procedure in particular – carotid endarterectomy – beta-blocker use has been shown to be especially problematic. People with atherosclerosis represent a vulnerable population to begin with, and CEA comes with a high potential for hemodynamic instability in the perioperative period, Dr. Stoner said. Moreover, studies used to establish the national beta-blocker protocols enrolled relatively few CEA patients.

In his presentation Wednesday on beta-blockers and CEA, Dr. Stoner will focus on results from his research group’s provocative 2014 study that looked at records from over 5,500 patients undergoing CEA, identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Of these, more than half were on beta-blockers prior to surgery.

The investigators found beta-blocker use associated with twice the odds of cardiac events, compared with patients not on beta-blockers (odds ratio, 1.97, confidence interval, 1.20-3.25, P = .01) and twice the odds of death (OR 2.01, CI: 1.01-4.01, P = .047), even after controlling for confounders.

Now, Dr. Stoner and colleagues are seeking to validate these findings in a prospective study of CEA patients using the Vascular Quality Initiative database. This will help determine, Dr. Stoner said, whether patient selection or a true beta-blocker effect was responsible for what was seen in the prior study.  
“We have to go back and prospectively look at this and ask are we over beta-blocking – and this is just one surgery,” he said.

Dr. Stoner said he thinks the keys to good management may lie in the dosing and timing of these agents, both of which need to be carefully investigated.

“The medical management of patients having surgery for atherosclerosis is still understudied,” he said. “To really understand it, you probably need a large-scale prospective registry,” he said, with tens of thousands of patients. “There are just so many medications, and the problem is most of the registries don’t have granularity as to the dosing and the timing.”

Dr. Stoner said that it’s likely a subset of patients will benefit from continued beta-blocker use while another subset will not. It is possible that patients on anti-hypertensive agents that promote hemodynamic instability, such as ACE inhibitors, could be at higher risk and may require a more careful approach.

In the meantime, he said, it is possible to adopt a more cautious and flexible approach to beta-blocker use institution-wide, as the University of Rochester Medical Center is now doing. How to implement this approach will be a main focus of Dr. Stoner’s talk.

Beta-blocker use should not be approached as a yes-or-no question, he said, as their optimal use requires more than checking a box as a protocol.

“On the chart we try to document beta-blocker use carefully,” Dr. Stoner said. “We don’t overuse beta-blockers for SCIP prophylaxis reasons. We won’t start patients on a beta-blocker if they weren’t previously on one, and we try to lower the dosage with patients on higher doses.”

The SCIP measures, while promoting beta-blockers in surgery, do not mandate them. “There’s enough flexibility in the guidelines that centers that can adapt care processes like we did in our institution, that are not being overly aggressive with them and documenting carefully, they’ll be okay,” Dr. Stoner said. “But I worry that when these guidelines came out it pushed people toward overuse of beta-blockers.”

Session 31: How Should Beta-Blockers be Used in Vascular Patients Undergoing Procedures: Use and Overuse Can Harm Patients and Their Use Should Not be a Quality Metric

Wednesday, 6:57 a.m. – 7:03 p.m.

Grand Ballroom West, 3rd Floor

Use of beta-blockers in the perioperative period has served since 2010 as a key government quality indicator for patients undergoing surgery.

Protocols established by the National Surgical Care Improvement Project (SCIP) encourage the use of beta-blockers during the perioperative period. And yet optimal use of these agents in vascular procedures is far from established – with many surgeons and physicians concerned that the SCIP protocols have resulted in their overuse.

“Our ubiquitous use of these drugs is probably harming people, especially those on higher doses,” said Dr. Michael Stoner of University of Rochester (New York) Medical Center.

For one procedure in particular – carotid endarterectomy – beta-blocker use has been shown to be especially problematic. People with atherosclerosis represent a vulnerable population to begin with, and CEA comes with a high potential for hemodynamic instability in the perioperative period, Dr. Stoner said. Moreover, studies used to establish the national beta-blocker protocols enrolled relatively few CEA patients.

In his presentation Wednesday on beta-blockers and CEA, Dr. Stoner will focus on results from his research group’s provocative 2014 study that looked at records from over 5,500 patients undergoing CEA, identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Of these, more than half were on beta-blockers prior to surgery.

The investigators found beta-blocker use associated with twice the odds of cardiac events, compared with patients not on beta-blockers (odds ratio, 1.97, confidence interval, 1.20-3.25, P = .01) and twice the odds of death (OR 2.01, CI: 1.01-4.01, P = .047), even after controlling for confounders.

Now, Dr. Stoner and colleagues are seeking to validate these findings in a prospective study of CEA patients using the Vascular Quality Initiative database. This will help determine, Dr. Stoner said, whether patient selection or a true beta-blocker effect was responsible for what was seen in the prior study.  
“We have to go back and prospectively look at this and ask are we over beta-blocking – and this is just one surgery,” he said.

Dr. Stoner said he thinks the keys to good management may lie in the dosing and timing of these agents, both of which need to be carefully investigated.

“The medical management of patients having surgery for atherosclerosis is still understudied,” he said. “To really understand it, you probably need a large-scale prospective registry,” he said, with tens of thousands of patients. “There are just so many medications, and the problem is most of the registries don’t have granularity as to the dosing and the timing.”

Dr. Stoner said that it’s likely a subset of patients will benefit from continued beta-blocker use while another subset will not. It is possible that patients on anti-hypertensive agents that promote hemodynamic instability, such as ACE inhibitors, could be at higher risk and may require a more careful approach.

In the meantime, he said, it is possible to adopt a more cautious and flexible approach to beta-blocker use institution-wide, as the University of Rochester Medical Center is now doing. How to implement this approach will be a main focus of Dr. Stoner’s talk.

Beta-blocker use should not be approached as a yes-or-no question, he said, as their optimal use requires more than checking a box as a protocol.

“On the chart we try to document beta-blocker use carefully,” Dr. Stoner said. “We don’t overuse beta-blockers for SCIP prophylaxis reasons. We won’t start patients on a beta-blocker if they weren’t previously on one, and we try to lower the dosage with patients on higher doses.”

The SCIP measures, while promoting beta-blockers in surgery, do not mandate them. “There’s enough flexibility in the guidelines that centers that can adapt care processes like we did in our institution, that are not being overly aggressive with them and documenting carefully, they’ll be okay,” Dr. Stoner said. “But I worry that when these guidelines came out it pushed people toward overuse of beta-blockers.”

Session 31: How Should Beta-Blockers be Used in Vascular Patients Undergoing Procedures: Use and Overuse Can Harm Patients and Their Use Should Not be a Quality Metric

Wednesday, 6:57 a.m. – 7:03 p.m.

Grand Ballroom West, 3rd Floor