1. Patient selection and treatment:

1. Surgery - infrainguinal revascularization or elective AAA
2. Clinical risk factors present (age, history of CHF, etc.)
3. Positive dobutamine stress echocardiogram demonstrating myocardium at risk (173 of 1351 patients who presented for these operations at eight different medical centers)
4. Exclusion of 53 patients already on beta blockers, and of those with extensive wall motion abnormalities, asthma, or severe left main or three vessel coronary disease
5. Prospective randomization of remaining patients to standard therapy or beta-blocker. Treatment was not blinded, and doctors could administer beta blockers to patients if signs of ischemia were accompanied by tachycardia.
6. Preoperative institution of beta-1 selective antagonist bisoprolol (range, 7-89 days of therapy before surgery; mean, 37 days), with continuation of therapy to at least 30 days.
7. Daily dosing of 5 mg in 44 patients, 10 mg in the 15 others. This did not exacerbate the peripheral vascular disease preoperatively. On the day of surgery, bisoprolol was given orally, and on the day after surgery was given orally or by NG tube or IV.

1. Preoperative and perioperative heart rates were significantly slower in the bisoprolol group.
2. There were 2 deaths in the bisoprolol group; 9 in the control group.
3. There were 0 non-fatal MI's in the bisoprolol group vs. 9 in control group.
4. 3.4% of patients in bisoprolol group died or experienced MI compared to 34% in the control group.

Now you may say that's ridiculous—we never see a 34% rate of complications in MY practice. And that is true. Remember that eight different medical centers combed their patient populations to get high-risk patients ONLY (with clinical risk indicators and confirmed abnormal dobutamine stress echoes). This high-risk group had a 28% rate of death/non-fatal MI in another study, so the results here are reasonable.

A previous study by Mangano et al demonstrated greater long-term survival after atenolol use, but no obvious effect on in-hospital mortality [2]. The study group did show a 50% decrease in ischemia perioperatively, however. The lack of effect on in-hospital mortality/MI was due to the low incidence of severe events (3%), reflecting the chosen study population (known CAD and/or risk factors for CAD in Mangano et al vs. dobutamine stress echo-proven myocardium at risk in this new study). Patient selection was probably key in the ability of this study to show a difference

Conclusions
The study authors suggest beginning beta-blockade 1-2 weeks preoperatively, reducing heart rate to less than 70 bpm preoperatively, and keeping it below 80bpm perioperatively. They recommend that treatment be continued at least 2 weeks postoperatively.

The editorial that accompanies this study asks the following very pertinent questions:

1. Does beta-blockade work on lower risk groups?
2. Does this strategy work on non-vascular procedures?
3. Does beta blockade have to be started at least 7 days in advance?
4. Are other beta blockers equivalent to bisoprolol.
5. Is beta 1 selectivity necessary?

The editorialist then goes on to make several recommendations based on his own risk stratification research, which are not repeated here [3]. With regard to approaching the vascular surgery patient, he suggests that after identification of high and intermediate risk patients, one should begin preoperative beta blockers. Furthermore, one should consider cardiac catheterization and revascularization only where that would be an appropriate part of the patient's long term care, rather than as an adjunct to planned vascular surgery.

Having digested all of the above, the main question now is whether the average life expectancy and quality of life of a vascular surgery patient is most improved by (A) screening coronary disease and pursuing interventions like revascularization (and at what cost) and/or (B) proceeding with the planned vascular surgery while on beta-blockers.