|
June 1998
Notes from the SCA
Conference Coverage by Dr. David Lubarsky
The annual meeting of the Society of Cardiovascular Anesthesiologists (SCA) is one of the best attended anesthesia conferences in the world. Held during the last week of April in beautiful Seattle, it was my pleasure to attend. Not only did I get to see the city, eat at great restaurants, and hit the Nike Town store for the best (and most expensive) athletic wear selection I've ever seen, but the conference was actually downright interesting.
The best part of the conference occurred on Monday. Entitled "Perioperative
Beta Blockers are Standard of Care - Pro and Con," the forum really took on
an aura of "Clash of the Titans." Dennis Mangano, from UCSF and the McSPI research
group, squared off against Lee Fleisher of Johns Hopkins took on one another.
Both are extremely well published, and are intelligent researchers in the field
of perioperative ischemia. The forum was conducted without any animosity (less
entertainment but more educational value), and concentrated on differing interpretations
of data. Dr. Mangano relied specifically on his recent NEJM article that utilized
atenolol as the perioperative beta blocker of choice (Click
here for Dr. Lubarsky's Review of that paper).
Basically, Dr. Mangano reiterated the findings of that study, indicating that the work was fairly definitive, that beta blockers clearly affect mortality, and should therefore be employed. He recounted an anecdotal story of two cardiologists in the San Francisco area who had recently been sued (and settled) for NOT using beta blockers perioperatively in patients at risk for CAD who subsequently went on to suffer myocardial infarction. So, regardless of the medical community's position on the issue, society has already interpreted the results of his study to indicate a new standard of care.
Dr. Fleisher countered by arguing that no legal precedent had been set by these instances as the reported cases were settled without a court ruling. And even if a court had ruled on these cases, it would still be up to the medical community to decide what is and is not mandated as appropriate care. While conceding that Mangano's study was a great leap forward in the perioperative management of patients with CAD, Dr. Fleisher noted that there were several problems. First, the results showing lower mortality for up to two years postoperatively were serendipitous. This was not a hypothesis-driven experiment (the only REAL kind that counts). No one specifically said, "I hypothesize that if we set up two equal groups and give one beta blockers, long-term postoperative mortality rates will be decreased in the treatment group." Second, the study's 200-odd patient sample size is insufficient to base a standard of care upon. Third, the study participants were all veterans, which means possible co-morbidities might be greater than the average patient's. The greatest correlation with postoperative morbidity was diabetes, not the use of beta blockers. Finally, the groups -- those who got, and those who did not get beta blockers -- were NOT identical. Although not statistically significantly, there was a trend that patients with greater disease were in the non-beta blocker group. The fact that there were no statistically different characteristics (diabetes, CAD, previous MI, etc.) among the groups simply meant that random sampling was a possible cause of the distribution of characteristics within each group. The observed trend toward greater severity of illness in the group who did not take beta blockers, however, could still have influenced differences seen in the study. A larger study with clearly equal groups is absolutely necessary before declaring that beta blockers are a new standard of perioperative care. Personally, I agree with Dr. Fleisher, and hope that such a study will soon be done.
The weekend prior to the main meeting offered a variety of worthwhile workshops. Having spoken at the one on economics, I will spare you the details, but will note that there was a remarkably interested and involved audience with salient and well informed opinions on issues of cost containment, practice standardization, and the effects of cost containment on practice autonomy. The other faculty members for that workshop (Paul Barash, Yale; Mike Roizen, Chicago; Jamie Ramsay, Emory; Davy Cheng, Toronto; Joyce Wahr, Michigan) were, frankly, both well spoken and incredibly knowledgeable about costs, economic credentialing and scorecards, information systems, and anesthesiologists' effects on the economics of postoperative care.
With regard to other workshops, the best-attended and talked-about were those on transesophageal echocardiography. Both the beginner and advanced workshops were apparently VERY pertinent and user friendly (a rare event at most meetings). To top things off, a rigorous credentialing exam was given, provoking many complaints about the unreasonable number of physics questions. But what test-taker ever approved of an examination they were forced to take?
All in all, this was, as usual, an extremely well-planned and intellectually invigorating conference.
Return to the Current Literature Review Front Page
|
