The AHA Guidelines and Scientifi c Statements Handbook
with major adverse effects, which most individuals
believe would outweigh any positive effects. It is
unknown if starting these agents at least 7 days
before surgery would lead to lower rates of death
or stroke, while maintaining the benefi t for reduc-
ing perioperative MI, and further research is
warranted.
In an accompanying commentary, Fleisher and
Poldermans suggest that the higher rate of stroke and
death in the metoprolol succinate may be related to
the dose given in the trial [29]. They further suggest
that for those patients with indications for periopera-
tive β-blocker therapy, but in whom there is insuffi -
cient time to appropriately titrate the medication, the
overriding theme is that tachycardia due to periop-
erative events, i.e. bleeding, hypovolemia, inadequate
control of pain or infection, should not be initially
treated with additional β-blocker but the underlying
cause of these conditions should be treated fi rst. If
tachycardia persists, then they recommend that β-
blocker can be used cautiously in high-risk patients
with proven or suspected coronary artery disease,
preferably supervised in the perioperative setting by
physicians who have experience with perioperative
hemodynamics such that hypotension and other
hemodynamic aberrations which may have led to the
increased incidence of stroke or septic death are
avoided. The AHA/ACC Guideline Committee had
not reviewed the trial to make a formal recommenda-
tion at the time of this publication.
There are several other major areas requiring
further research. While the current Guidelines advo-
cate continuing statin therapy in the perioperative
period, further trials are needed to determine if
starting statin therapy would be benefi cial. Addi-
tionally, there is signifi cant debate regarding the
optimal perioperative management of patients with
coronary stents. Specifi cally, information is needed
on the safe time interval to wait before operating on
patients with drug-eluting stents and the ideal man-
agement of anti-platelet agents. Finally, information
is required to determine the optimal strategy to
monitor patients for perioperative cardiac events
and how this information should be utilized to
inform long-term care.References available online at http://www.Wiley.com/go/
AHAGuidelineHandbook.