Download Which surgical patients benefit from perioperative beta

 The authors noted insufficient evidence to
recommend any specific treatment or combination
of treatments for varicose veins (evidence rating B
“inconsistent or limited-quality patient-oriented
evidence). Sclerotherapy was noted for improving the
symptoms or cosmetic appearance of varicose veins
(evidence rating of B).4
Megha Manek, MD
Andrew Kayes, MD
Michael Sidhom, MD, MSPH
Michael Gillan, DO
Guthrie Clinic/Robert Packer Hospital
Sayre, PA
1. Shingler S, et al. Cochrane Database Syst Rev. 2011; (11):CD008819. [STEP 1]
2. Nesbitt C, et al. Cochrane Database Syst Rev. 2011; (10):CD005624. [STEP 1]
3. Tisi PV, et al. Cochrane Database Syst Rev. 2006; (4):CD001732. [STEP 1]
4. Jones R, et al. Am Fam Physician. 2008; 78(11):1289–1294. [STEP 5]
Which surgical patients benefit
from perioperative beta-blockers?
Evidence-Based Answer
In patients undergoing cardiac or vascular surgery or
patients with cardiac risk factors undergoing nonvascular
surgery, perioperative beta-blockers reduce 30-day
risk of acute myocardial infarction (NNT=57) and
1-year mortality (NNT=28), but do not change 30-day
mortality. This benefit is partially offset by increased
risk of stroke (NNH=177) (SOR: A, meta-analysis of
RCTs). Patients with 2 or more Revised Cardiac Risk
Index (RCRI) factors taking beta-blockers have a lower
30-day mortality than patients not taking beta-blockers
undergoing vascular or nonvascular surgery (SOR: B,
single cohort study).
A meta-analysis of 27 parallel RCTs with 13,550
patients evaluated mortality and other major outcomes
in patients undergoing surgery who either stopped
or added a perioperative beta-blocker.1 The trials
included a variety of beta-blockers at standard doses.
Surgeries were primarily cardiac or vascular with some
nonvascular surgeries in patients with cardiac risk
factors.
The addition of a beta-blocker during the
perioperative period did not change 30-day mortality
compared with control groups in which most patients
were not already taking a beta-blocker or beta-blockers
were stopped preoperatively (12 trials, n=11,101; risk
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Evidence-Based Practice / November 2015
ratio [RR] 0.91; 95% CI, 0.57–1.4), but did reduce
mortality at 1 year (4 trials, n=781; RR 0.55; 95%
CI, 0.31–0.99; NNT=28). Adding a beta-blocker also
reduced the 30-day risk of acute myocardial infarction
compared to similar control groups (15 trials,
n=12,224; RR 0.65; 95% CI, 0.47–0.88; NNT=57), but
increased the 30-day risk of stroke (8 trials, n=11,737;
RR 2.2; 95% CI, 1.4–3.4; NNH=177).1
A multicenter, retrospective, cohort analysis at
104 VA medical centers from 2005 to 2010 examined
perioperative beta-blocker exposure in 136,645 patients
undergoing inpatient or outpatient noncardiac surgery
(vascular and nonvascular).2 This trial matched patients
exposed to beta-blockers 1:1 with those not exposed
and adjusted for underlying conditions that would lead
to beta-blocker therapy using propensity scores (37,805
pairs). The groups were substratified using the following
RCRI variables: high-risk surgery, cerebrovascular
disease, ischemic heart disease, congestive heart failure,
diabetes mellitus, and renal insufficiency.
There were significant associations between betablocker exposure and lower 30-day all-cause mortality
in patients with 2 factors (RR 0.63; 95% CI, 0.50–
0.80; NNT=105), 3 factors (RR 0.54; 95% CI, 0.39–
0.73; NNT=41), and 4 or more factors (RR 0.40; 95%
CI, 0.25–0.73; NNT=18) compared with patients not
exposed to beta-blockers. No difference was noted
in outcomes among patients with 0 or 1 risk factor.
Among the matched cohorts, the incidence of stroke
did not differ from between the beta-blocker group and
the no beta-blocker group. The subgroup undergoing
vascular surgery showed no significant change in
30-day mortality or cardiac morbidity compared with
nonvascular surgery patients.2
A 2009 American College of Cardiology
Foundation/American Heart Association (ACCF/AHA)
policy statement recommended the continuation of
beta-blockers perioperatively in patients already taking
a beta-blocker (Class I recommendation, evidence
obtained from at least 1 properly designed RCT).3 They
recommended the use of a perioperative beta-blocker
in patients with inducible ischemia, coronary artery
disease, or multiple RCRI factors undergoing vascular
surgery and in patients with coronary artery disease
or multiple RCRI factors undergoing intermediaterisk surgery (Class IIa recommendation, evidence
obtained from well-designed controlled trials without
randomization).
They also stated the role of perioperative betablocker treatment in low-risk patients is uncertain (Class
IIb recommendation, evidence obtained from welldesigned cohort or case-control analytic studies). They
did not recommend the routine use of perioperative
high-dose beta-blockers (Class III recommendation,
opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees).3
Monique Forsea, MD
Philipp Narciso, MD
UAMS – South FMRP
Magnolia, AR
1. Guay J, et al. J Cardiothorac Vasc Anesth. 2013; 27(5):834–844. [STEP 1]
2. London MJ, et al. JAMA. 2013; 309(16):1704–1713. [STEP 3]
3.American College of Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines. J Am Coll Cardiol. 2009; 54(22):e13–e118. [STEP 5]
What patient population is at greatest risk
of having latent tuberculosis and require
treatment?
Evidence-Based Answer
The literature does not provide guidelines on when to
start treatment for latent tuberculosis (TB). Foreignborn patients should be screened and treated for latent
TB infection upon diagnosis to prevent the development
of active TB infections, which are most likely to occur
within 2 years of arrival to the United States (SOR: B,
observation and epidemiologic trials).
A retrospective cohort trial examined the impact
of immigration on cases of active TB in the state of
Connecticut between 1995 and 2006.1 During this time,
1,152 cases of active TB were reported, 662 of which
were among foreign-born persons.
The incidence of active TB was much greater for
foreign-born persons compared with US-born persons
(20 vs 1.5 per 100,000 person-years; RR 13; 95% CI,
9.2–20). Of foreign-born persons, refugees had the
highest incidence rate in the first year after US entry
(116/100,000 person-years). Refugees accounted for
4% of cases among the foreign-born. This finding may
have been due to overseas screening in this group. Other
risk factors for developing active TB included HIV
infection, a history of alcohol or drug abuse, residence
in a correctional facility, and homelessness.1
Most cases of active TB are thought to be a
reactivation of latent TB infection (LTBI).2 An
epidemiologic analysis reviewed all active TB cases
among foreign-born persons in the United States to
determine which population subgroups were at the
highest risk for developing active TB in order to better
target screening and treatment for LTBI. From 2001 to
2006, nearly 47,000 cases of active TB among foreignborn individuals were reported. The highest rate
(75 cases/100,000 persons) of active TB was within
2 years of entrance into the United States. This rate is
3 to 7 times higher than the rate of active TB diagnosed
in foreign-born persons living in the United States
longer than 2 years.
Those entering the United States from Southeast
Asia (100/100,000) and sub-Saharan Africa
(250/100,000) had the highest rates of active TB.
However, the rate of active TB among foreign-born
individuals (10/100,000) remained higher than that
of US-born persons (<2.5/100,000) after as many as
20 years after entrance into the United States (no
P value provided). Case rates of active TB also increased
with age among recent (<2 years) and nonrecent
entrants to the United States.2
In 2000, the CDC recommended screening for
LTBI in groups determined to have a high likelihood of
developing active TB.3 These groups included patients
born in endemic countries, those with certain medical
conditions including HIV and injection drug use, and
workers in high-risk settings (for example, health
care workers). Screening was recommended with
the tuberculin skin test. Treatment with rifampin or
isoniazid was recommended for those determined to
have LTBI regardless of age.
Based on expert opinion, pregnant women at
high risk for developing active TB should be treated
with isoniazid, which should be initiated regardless of
trimester. High-risk pregnant women include those who
are HIV positive or have had a recent exposure to active
TB. Pregnant women at low risk may defer treatment
EBP
until postpartum.3
Meghan Hughes, MD, MPH
Jay H. Lee, MD
University of Colorado FMR
Denver, CO
1. Lobato MN, et al. Int J Tuberc Lung Dis. 2008; 12(5):506–512. [STEP 3]
2. Cain KP, et al. JAMA. 2008; 300(4):405–412. [STEP 3]
3.American Thoracic Society. MMWR Recomm Rep. 2000; 49(RR-6):1–51. http://www.
cdc.gov/mmwr/preview/mmwrhtml/rr4906a1.htm. Accessed October 19, 2015. [STEP 5]
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