To the editors:—We thank Drs. Mostafaie and Harrington for their comments and agree that the literature on perioperative β-blockade has been limited by observational studies and a small number of randomized trials. Given the underutilization of preoperative β-blocker we observed, we hypothesized that questions regarding appropriate patient selection may be contributing to this finding, although we did not test this hypothesis in our study. During the planning stages of our quality initiative, the 2002 ACC/AHA guidelines and the then recent review by Auerbach and Goldman, while consensus opinions provided a graded evaluation of the quality of the evidence supporting perioperative β-blocker use in light of conflicting published results at that time.1,2 The authors site several primary studies and a review published after the completion of our quality initiative that do not support the use of perioperative β-blocker in select populations. However, these were not available at the time of our study. While we agree that more information has been gained and questions raised we are still cautious in drawing conclusions from recent studies owing to ongoing methodologic concerns. For instance, the Metoprolol after vascular surgery (MaVS) unpublished study reported few events and is likely underpowered for their primary outcome.3 While the review by Devereaux et al.4 included heterogeneous studies of varying patient populations, we believe the updated 2006 ACC/AHA clinical guidelines are useful in their assessment of the strength and quality of ongoing research, with size of the study being only one factor, balanced by the cumulative evidence to date. Beyond these guidelines, we agree that the POISE trial and other well designed large studies should provide more definitive answers and shape clinical practice.


  1. Top of page
  • 1
    Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary: a report of the American college of cardiology/American heart association task force on practice guidelines (committee to update the 1996 guidelines on perioperative cardiovascular evaluation for noncardiac surgery). J Am Coll Cardiol. 2002;39:54253.
  • 2
    Auerbach AD, Goldman L. {beta}-Blockers and reduction of cardiac events in noncardiac surgery: scientific review. JAMA. 2002;287:143544.
  • 3
    Yang H, Raymer K, Butler R, Parlow J, Roberts R. Metoprolol after vascular surgery (MaVS). Can J Anesth. 2004;51 (suppl_1):A7.
  • 4
    Devereaux PJ, Beattie WS, Choi PTL, et al. How strong is the evidence for the use of perioperative {beta} blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials. BMJ. 2005;331:31321.