13. Patient Profiles:
Holter Detected Arrythmias POD 0-7
What about arrythmias? Well, the patients treated
with perioperative beta blockers had a lower heart rate. The heart
rates were not that low, in the atenolol treated patients they
averaged 75 beats per minute and in the placebo treated patients
87. There are a number of "experts" who insist that
perioperative beta blockers must be titrated to effect heart rate.
The point I want to make here is simple. In the atenolol study,
we held the drug if the heart rate was too low (below 55 beats
per minute). We did not titrate to effect. Titrating to effect
may be better, but it is NOT essential. What you should do is
GIVE THE DRUG. Once you have GIVEN THE DRUG to lots of people,
like everyone who either has coronary artery disease, everyone
who has peripheral vascular disease, and everyone with two risk
factors for coronary artery disease which includes (OK, everyone,
I have repeated it enough times you can all sing along with me)
hypertension, hyperlipidemia, age greater than or equal to 65,
smoking, or diabetes. Then you have permission to get fancy and
titrate to dose. If you are not treating every candidate, then
concentrating on having a really complicated system with dose
titration to effect in the sickest patients, misses treating the
majority of patients and is a disservice.
So in summary, GIVE THE DRUG. GIVE THE DRUG TO EVERYONE WITH
RISK. Get fancy later.
