December 28, 2007
Sidney Goldstein, MD, Medical Editor
5635 Fishers Lane, # 6000
Rockville, MD, 20852
Regarding the 12/07 article “Perioperative Beta Blocker Regimen Boosts Risk” article in Cardiology News by Mitchel L. Zoler of the Philadelphia Bureau.
First of all, Sid, thanks for taking the time to read this letter, and I hope you enjoy my handouts/cooking DVD. It was nice to speak with you again at the last ACC. Feel free to read, edit, file in the circular filing cabinet, or print the enclosed.
I was astounded to read the 12/07 Cardiology News summary concerning the beta blocker regimen, the blanket and pejorative comments by Judith S. Hochman, MD, (perhaps her comments as quoted were taken out of context & therefore my apologies for my critical comment), and most particularly the design of the Perioperative Ischemic Evaluation (POISE) Trial. Who decided to use such a high dose of beta blockade (long acting 100 mg Toprol XL as metoprolol CR) such a short time (2-4 hours) prior to surgery? Where did the assumption come from that beta-blockers can adequately block the essential effects after a single dose? Heart rate & blood pressure are valuable surrogates,
but do not prove adequate catechol surge/ischemic disease protection. Why was such a high dose (100 mg metoprolol CR) given again six hours postoperatively? In my estimation, no wonder this approach resulted in such a high frequency of adverse events in this POISE trial.
For 15 years I have given either 25 mg metoprolol (Lopressor) short-acting BID or more preferred Toprol 25 mg XL beta blockade once at bedtime beginning four nights before through three nights after surgery, along with 2.5 mg of Norvasc and 40 mg of Lipitor to “all comers” except the “young” or those with no cardiovascular risk factors such as those having a total cholesterol of less than 150. Using this regimen, no patient of mine has developed any perioperative ischemic event following any non-cardiac surgery during this 15-year period.
My implied suggestion is that perhaps a lighter and gentler hand dosing the beta blocker, as well as the addition of other anti-ischemic therapies for those undergoing surgery, might have prevented such a high complication rate.
It is understandable, by virtue of Astra Zeneca (the manufacturer of Toprol XL)’s funding and researchers’ wish to control all but a single variable, that the POISE trial was designed as such.
However, the major perioperative complications are not due to a disease that has a single origin such as just a catechol surge, but is a disorder that requires a multifactorial & perhaps a longer timespan
therapeutic approach such as I have implied above in my best guess approach. No doubt the recommendation for the use of beta-blockers should be revised, but that does not mean that beta-blockers are not indicated, simply that the frequency/dose/duration and possibly even specific beta-blockers may need to be recommended in concert with other therapies. Further research is indicated and a more reasoned word choice in making comments about drug usage is clearly indicated.
I have no relevant disclosures.
H. Robert Silverstein, MD, FACC
Medical Director, Preventive Medicine Center