Archive for the ‘Beta blockade’ Category

Yale Anesthesia Grand Rounds. Apr 28, 2017. Preop Cards Eval: Guidelines vs “Real World”

Wednesday, April 26th, 2017

2017_04_24 Ellis Preop Cardiac Evaluation

PGA NYC Dec 2015: Preoperative Cardiac Evaluation 2015: Guidelines vs “The Real World?”

Saturday, December 12th, 2015

2015_12_12 PGA NYC Ellis Preop Cardiac Evaluation .pptx_Page_01

2015_12_12 PGA NYC Ellis Preop Cardiac Evaluation .pptx

 

 

At The 2013 NYSSA PGA Meeting

Thursday, December 19th, 2013

Ellis, NYSSA PGA

 

Saturday at NY State Society of Anesthesiologists PGA meeting, Dr. Ellis, Anesthesia Camp Course Director, moderated a panel and lectured on Perioperative Beta Blockade. Here are his Power Point slides: http://goo.gl/LnGWF8.

On Friday, Dr. Ellis also lectured at the PGA on Preoperative Cardiac Evaluation. Power Point slides: http://goo.gl/lM0Kqa.

What are this month’s beta blocker guidelines?

Saturday, August 17th, 2013

I (Dr. Ellis) am Anesthesia Camp Course Director.  I gave Grand Rounds at NYU last month.

I talked about Perioperative Beta Blockade; click here for a PDF of the slides shown.

Your feedback, of course is appreciated.

Does your institution have automated reminders to continue perioperative beta blockade in paients taking them chronically?

bleeding bad 2013_07_27 NYU  John Ellis Beta blockade copy.pptx
Several new studies suggest that while beta blockade may protect in the absence of hemorrhage, it may harm when bleeding increases.

 

Beta blockers protective in non-vascular noncardiac surgery, but not in vascular surgery???

Friday, April 26th, 2013

Dr London and colleagues from San Francisco VA have just published a study in JAMA (retrospective; propensity analysis) showing that beta blockers are NOT protective in vascular surgery.  However, they are in non-vascular noncardiac surgery.  The protection increases as the RCRI increases.

Hypotheses as to why no protection in vascular surgery patients:

  • More careful periop care in vascular surgery patients?
  • I think it’s because vascular surgery patients bleed more than others.  In Kamel et al (see below), vascular cases were only 12.5% of cases analysed, but 41% of hemorrhage cases, where definition of major hemorrhage was “requiring transfusion of >4 U of packed red blood cells (PRBCs) or whole blood based on the NSQIP definition”). “Bleeding is Rarely Good for You!” below is the accompanying editorial.

I asked Dr. London if they had analysed bleeding and transfusion in this cohort.  They’d like to do so, but await funding to be able to examine.

Circulation. 2012 Jul 10;126(2):169-71. doi: 10.1161/CIRCULATIONAHA.112.115196.

Circulation. 2012 Jul 10;126(2):169-71. doi: 10.1161/CIRCULATIONAHA.112.115196.

Circulation. 2012 Jul 10;126(2):207-12. doi: 10.1161/CIRCULATIONAHA.112.094326. Epub 2012 Jun 7. Association between major perioperative hemorrhage and stroke or Q-wave myocardial infarction. Kamel H, Johnston SC, Kirkham JC, Turner CG, Kizer JR, Devereux RB, Iadecola C. Source Department of Neurology and Neuroscience, Weill Cornell Medical College, New York, NY 10065, USA. hok9010@med.cornell.edu

Circulation. 2012 Jul 10;126(2):207-12. doi: 10.1161/CIRCULATIONAHA.112.094326. Epub 2012 Jun 7.
Association between major perioperative hemorrhage and stroke or Q-wave myocardial infarction.
Kamel H, Johnston SC, Kirkham JC, Turner CG, Kizer JR, Devereux RB, Iadecola C.
Source
Department of Neurology and Neuroscience, Weill Cornell Medical College, New York, NY 10065, USA. hok9010@med.cornell.edu

Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery Martin J. London, MD; Kwan Hur, PhD; Gregory G. Schwartz, MD, PhD; William G. Henderson, PhD, MPH JAMA. 2013;309(16):1704-1713. doi:10.1001/jama.2013.4135.

Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery
Martin J. London, MD; Kwan Hur, PhD; Gregory G. Schwartz, MD, PhD; William G. Henderson, PhD, MPH
JAMA. 2013;309(16):1704-1713. doi:10.1001/jama.2013.4135.

 

Another nail in the coffin for beta blockers? In this case, BB don’t help chronic AF/CHF patients as much.

Tuesday, February 5th, 2013

From Physicians First Watch:

Beta-Blockers Less Effective in Heart Failure with Atrial Fibrillation

By Joe Elia

Patients with heart failure and atrial fibrillation do not benefit as much from beta-blocker therapy as those with sinus rhythm, according to a meta-analysis in the Journal of the American College of Cardiology: Heart Failure.

Researchers analyzed mortality outcomes from four studies including over 8500 patients with heart failure and reduced left-ventricular ejection fraction (<40%). Roughly 20% also had atrial fibrillation. Although those with atrial fibrillation who received beta-blockers had lower mortality risks than those receiving placebo (odds ratio, 0.86), patients with sinus rhythm fared much better (OR, 0.63). In addition, beta-blockers did not reduce hospitalizations for heart failure among patients with atrial fibrillation, whereas they did among those with sinus rhythm.

Editorialists call the study, “hypothesis-generating,” and conclude that the results “at a minimum” suggest that treatment for those with heart failure and atrial fibrillation “should be approached differently” from those with sinus rhythm.

JACC: Heart Failure article (Free)

JACC: Heart Failure editorial (Free)

Our perioperative beta blockade review. Published Dec 2011, before Poldermans misconduct allegations

Friday, January 6th, 2012

Don Poldermans, of DECREASE beta blocker trials, fired.

Tuesday, November 29th, 2011

I’ve always been concerned about the generalizability of Poldermans’ work.  A PubMed search of his name and “vascular surgery” returns over 150 references.  His work has continued to support perioperative beta blockade while other studies, such as POISE, have found adverse outcomes.  He is lead author of the European Society of Cardiologists Perioperative Guidelines for Noncardiac Surgery.

Now, Prof Poldermans has been fired by Erasmus University, among allegations:

The professor is accused of faking academic data and compromising patient trust, the paper says. In particular, he failed to obtain patient consent for carrying out research and recorded results ‘which cannot be resolved to patient information,’ the university said.

Don Poldermans has spent years researching the risk of complications during cardio-vascular surgery and has some 500 publications to his name.

A spokesman for Poldermans told the paper he admitted not keeping to research protocols but denied faking data.

The ESC has therefore stated:

In its statement, the ESC said that the society is reviewing this document “in order to decide if these need to be re-examined in the light of recent events. A new statement will be issued by the ESC once a decision has been reached.”

Will medical therapy replace surgery for thoracic aneurysms?

Thursday, October 13th, 2011

Recent epidemiologic studies have shown lower rates of AAA.  Many ascribe this to better chronic treatment of hypertension.

Now Danyi et al have written a review article highlighting the potential for medical therapy to replace some surgery for thoracic aneurysms.

Specifically, they describe molecular mechanisms that may lead to aneurysm formation, and how:

  • Angiotensin receptor blockers (ARBs) are thought to inhibit the above pathways via inhibition of the AT1 receptors.
  • Angiotensin-converting enzyme inhibitors (ACEIs) block angiotensin II.
  • Statins block the NADH/NADPH system;
  • tetracyclines and macrolides reduce MMP activity. β-Blockers reduce shear stress on the vessel.

Given the high M&M of thoracic aortic surgery, even with endovascular and hybrid approaches, these are hopeful advances.

Fig. 2. MRI parasagittal gated image showing a saccular aneurysm of the aortic isthmus just distal to the left subclavian artery (white arrow). The cine-gradient echo image signal intensity in the aneurysm is inhomogeneous because of the intraluminal turbulence.

Video: Aug 2011 lecture Periop Myocardial Ischemia and Infarction

Tuesday, August 23rd, 2011

Medical University of South Carolina Grand Rounds

Dr. John E. Ellis

Start watching video at 2:20