Despite the proven effects of PCRRT for the reduction of perioperative mortality, the low cost per life saved and the adoption by the ACC and AHA in 1996 and the reissue in 2003^6,7 of perioperative perioperative cardiac risk reduction therapy using beta blockers or clonidine (PCRRT), changing physician practice is slow. In a recent survey 90% of anesthesiologists had heard of perioperative beta blockade (PCRRT) and 40% were using it.^28-30 Unfortunately, PCRRT therapy has not been adopted universally for a number of reasons including lack of education about the therapy, lack of knowledge about contraindications to beta-blockade, lack of understanding about how to implement an effective PCRRT program^29,30, anesthesiologist hesitation about prescribing an oral medication³¹, lack of feedback about the benefits of adopting PCRRT, and lack of feedback of the risks of not adopting the PCRRT program. Anesthesiologists started preoperative beta-blockers infrequently even in patients without contraindications.^31,32 Moreover, a significant fraction (30%) of high risk patients with clear indications for perioperative beta blockade, who are admitted on beta blockers, have them discontinued.³² These findings suggest that educating anesthesiologists about the perioperative use of beta-blockade may increase the use of this therapy proven to reduce perioperative mortality.^29,31

In international studies, 90% of anesthesiologists were aware of peri-operative beta-blockade, unfortunately specific protocols were available in only 10% of institutions.^28-30 To obtain a worldwide 90%

familiarity with and 40% using the therapy in less than a decade is phenomenal success for a therapy without any corporate support.²⁹ This accomplishment has been through academic detailing, national and international lectures, publications, adoption of therapy as a standard of care by the ACC and AHA, and web based education (www.betablockerprotocol.com). Despite this world wide recognition of the therapy, it is not utilized in all patients at risk. Epidemiologic analysis of one hospital's experience with perioperative care demonstrated that ninety-seven percent (97%) of the patients who developed postoperative MI could have been identified as being at increased risk for cardiac complications, and eighty-one percent (81%) appeared to be ideal perioperative beta-blocker candidates.³³ Treatment with a beta-blocker before infarction was associated with an odds ratio of in-hospital mortality of 0.19 (95% confidence interval, 0.04-0.87) (81% reduction in the risk of death).^33,34 A large percentage of the postoperative MI's could be prevented if a beta-blocker had been administered to all ideal candidates around the time of surgery. Use of beta-blockers before infarction reduces overall mortality, even among patients who go on to develop this complication.³³ Recently we demonstrated in a prospective randomized clinical trial that PCRRT with clonidine, an alpha-2 agonist also reduces 30 day and two year mortality.²⁴ This trial provides a second line agent for patients who have a specific contraindication to beta blockers.

The reductions in mortality with PCRRT can be most dramatic when there is a protocol in place to guide PCRRT.³⁵ In 1998, at the VAMC San Francisco we instituted a Perioperative Cardiac Risk Reduction Therapy (PCRRT) program in patients undergoing non-cardiac surgery. In reviewing our NSQIP data for the

years since instituting that policy, we have been a statistically significantly low outlier for 30-day mortality for major non-cardiac surgery for five or the last six years. Prior to the PCRRT program our five year average O/E ratio was 1.0. It has been clearly demonstrated in prospective randomized clinical trials that PCRRT reduces operative ⁴,²⁴ and long term mortality⁴,¹⁹,²⁴. Adoption of the clinical use of perioperative PCRRT with beta blockers at the VAMC San Francisco has cut our observed to expected operative mortality.³⁶

The American College of Cardiology and the American Heart Association have stated that perioperative beta blocker therapy for patients with elevated risk is a level 1 indication. The consensus of medical experts^25-27 suggest that perioperative beta blockers reduce operative mortality. The prospective, randomized, clinical trials and the epidemiologic analysis support the use of perioperative beta blockers. Use of perioperative beta blockade at the San Francisco VA is associated with a reduction in surgical mortality. It is time to implement a program at your hospital for perioperative beta blockade protocols which combined with education, computerized analysis of compliance rates, feedback of compliance rates and associated mortality rates, and computerized reminders in medical record systems can reduce surgical mortality and reduce patient care costs.

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