ISCHAEMIC HEART DISEASE

Perioperative β blockade for non-cardiac surgery ▸

Although suggestive small trials have been done, no large scale randomised trials have been undertaken to assess routine perioperative β blockade to reduce cardiovascular risk. This study of “real life” assessed 782 969 patients, of whom 663 635 (85%) had no recorded contraindications to β blockers, and 122 338 of whom (18%) received such treatment during the first two hospital days. High risk patients made up 44%, with a revised cardiac risk index (RCRI) score of 4 or higher. This index stratifies the risk of perioperative cardiac events according to the type of surgery and the presence or absence of a history of ischaemic heart disease, congestive heart failure, cerebrovascular disease, preoperative treatment with insulin, and a preoperative serum creatinine concentration > 2.0 mg/dl (176.8 µmol/l). The relation between perioperative β blocker treatment and the risk of death varied directly with cardiac risk; among the 580 665 patients with an RCRI score of 0 or 1, treatment was associated with no benefit and possible harm, whereas among the patients with an RCRI score of 2, 3, or 4 or more, the adjusted odds ratios for death in the hospital were 0.88 (95% confidence interval (CI) 0.80 to 0.98), 0.71 (95% CI 0.63 to 0.80), and 0.58 (95% CI 0.50 to 0.67), respectively. This study suggests that all patients with above average cardiac risk should be treated with these drugs in the perioperative period. This would surely include all vascular surgery.

Statins for all diabetics on dialysis? ▸

The recent collaborative atorvastatin diabetes study (CARDS) …