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In the News

From the February ACP Hospitalist, copyright © 2010 by the American College of Physicians

Updated guidelines on perioperative beta-blockers

Updated guidelines on the use of perioperative beta-blockers recommend against routinely starting high-dose beta-blockers without dose titration in patients undergoing noncardiac surgery.

The update, issued by an American College of Cardiology Foundation/American Heart Association task force, notes new evidence from the PeriOperative Ischemic Evaluation (POISE) trial, which found that the cardioprotective effect of perioperative beta-blocker therapy was offset by an increased risk of stroke and total mortality. The update gives a class IIa recommendation for titrating beta-blockers to heart rate and blood pressure in patients undergoing vascular surgery who are at high cardiac risk due to coronary artery disease or cardiac ischemia found on preoperative testing.

Initiation of beta-blocker therapy in lower-risk patients calls for careful assessment of the risks and benefits, the authors said. They suggest initiating therapy well before a planned surgical procedure and implementing careful titration to achieve heart rate control while avoiding frank bradycardia or hypotension. Based on the POISE results, physicians should not routinely administer perioperative beta-blockers in high, fixed doses beginning on the day of surgery, they said.

The task force concluded that current evidence supports ongoing examination of indications for and contraindications to beta-blocker therapy throughout the postoperative period. The complete recommendations were published in the Nov. 24, 2009 Journal of the American College of Cardiology and the Nov. 24, 2009 Circulation.

‘Get With the Guidelines’ improved disparities in heart disease treatment

Hospitals that participated in a national quality improvement program for heart disease have almost eliminated gender and age disparities in evidence-based treatment, although small differences remain, a recent analysis found.

Researchers studied trends in treatment among 237,225 patients hospitalized with coronary artery disease (CAD) at hospitals participating in the American Heart Association/American College of Cardiology’s Get With the Guidelines-CAD program from 2002 to 2007. Adherence to six quality measures (aspirin on admission and discharge, beta-blockers at discharge, angiotensin-converting enzyme [ACE] inhibitor or angiotensin-receptor blocker [ARB] use, lipid-lowering medication use, and tobacco cessation counseling) improved from 86.5% to 97.4% in men and from 84.8% to 96.2% in women over the study period. Adherence in elderly patients also increased, although the improvement was not as high in those at least 75 years old compared with patients younger than 75. The study was published in the November 2009 issue of Circulation: Cardiovascular Quality and Outcomes.

While the study showed improvement overall, men under age 75 still were more likely than women under age 75 to receive recommended lipid-lowering medications at discharge, the authors said. In addition, men were more likely than women to receive all of the evidence-based therapies.

Future research should examine the reasons for the remaining treatment differences and develop strategies to close the gaps, the authors said. In particular, hospitals should look at why age- and sex-based treatment gaps persist in lipid treatment, use of ACE inhibitors or ARBs for left ventricular dysfunction, and smoking cessation counseling.

Rapid transfer to ICU improves outcomes for severe CAP patients

Same-day admission to the intensive care unit was associated with better outcomes for patients with severe community-acquired pneumonia, even when patients did not have obvious indications for ICU transfer, a recent study reported.

Researchers analyzed four studies including a total of 453 adult patients with community-acquired pneumonia (CAP) who were transferred to intensive care units within three days of arriving at the emergency department. Delayed ICU transfer was associated with a higher risk of 28-day mortality and longer length of stay than direct transfer. The results were the same even after researchers excluded 150 patients with an obvious indication for immediate ICU admission. The study appeared in the November 2009 Critical Care Medicine.

Guidelines from the Infectious Diseases Society of America/American Thoracic Society recommend direct transfer to the ICU from the ED for patients who meet at least one major criterion for severe CAP. However, the authors noted, the current findings suggest that the criteria should be expanded because a significant number of patients who don’t meet them are at risk for organ failure and adverse outcomes.

Better prediction models for severe sepsis are needed in order to identify CAP patients at highest risk for adverse outcomes, the authors said. The study results may help rationalize the decision to admit patients to the ICU, they continued, whereas currently the decision is an individual clinical judgment. They noted that early ICU admission was associated with shorter length of stay for survivors, which may help alleviate the shortage of ICU beds. Early identification of ICU patients would also allow physicians more time to discuss treatment options with patients and their families.

In the News is a product of ACP HospitalistWeekly, an e-newsletter provided every Wednesday by ACP Hospitalist. If you’re not already receiving ACP HospitalistWeekly, contact Customer Service at 800-523-1546, ext. 2600, or directly at 215-351-2600 (M-F, 9 a.m. to 5 p.m. EST) or send an e-mail.

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© 2010 ACP Hospitalist and American College of Physicians

ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated