Questions · Perioperative Beta-Blocker Management
10 questions, 0 approved. Approve them one at a time — a quiz shows nothing you have not.
Recall — derived from a kept point
In the POISE trial, extended-release metoprolol was started before noncardiac surgery. State what happened to myocardial infarction, death, and stroke, giving the event rates for each, and summarise in one sentence the trade-off the trial demonstrated.
Answer: Myocardial infarction fell from 5.7% to 4.2%, but death rose from 2.3% to 3.1% and stroke doubled from 0.5% to 1.0%. The trial traded fewer myocardial infarctions for more deaths and twice as many strokes.
POISE is why starting a beta-blocker to prevent infarction is not a free move: the infarctions prevented came alongside more deaths and double the stroke rate.
Source claim: Starting extended-release metoprolol before noncardiac surgery reduced myocardial infarction from 5.7% to 4.2% but increased death from 2.3% to 3.1% and doubled stroke from 0.5% to 1.0%.
Effects of Extended-Release Metoprolol Succinate in Patients Undergoing Non-Cardiac Surgery (POISE Trial): A Randomised Controlled Trial, Lancet (London, England) 2008
recall · CA-2 · phrased by llm
Name the two ultra-short-acting beta-blockers described for use in the perioperative period and in critically ill patients, and state the specific advantage they are said to have over long-acting beta-blockers once a dose has already been given during a case.
Answer: Esmolol and landiolol. They offer the effects of beta-blockade without the detrimental effects of long-acting agents, which are hard to counteract once they have been given perioperatively.
The appeal of esmolol and landiolol is that the exposure is short: with a long-acting beta-blocker, once it is in, its effects are hard to counteract for the rest of the case.
Source claim: Ultra-short-acting agents such as esmolol and landiolol offer the effects of beta-blockade without the detrimental effects of long-acting agents, which are hard to counteract once given perioperatively.
Ultra-Short-Acting Β-Blockers (Esmolol and Landiolol) in the Perioperative Period and in Critically Ill Patients, Journal of cardiothoracic and vascular anesthesia 2018
recall · CA-1 · phrased by llm
A study of perioperative beta-blocker therapy after major noncardiac surgery analysed survival by Revised Cardiac Risk Index score. Describe how the relationship between beta-blockade and survival varied across the risk spectrum, and state what kind of relationship the study supports.
Answer: The association between perioperative beta-blockade and survival tracked baseline risk: benefit appeared at a Revised Cardiac Risk Index of 2 or more, with no benefit and possible harm at a score of 0 or 1. It is an association with survival across risk strata, not a demonstrated causal effect of beta-blockade.
Stratify before you generalise: the survival association here sat with a Revised Cardiac Risk Index of 2 or more, and at 0 or 1 it pointed to no benefit and possible harm.
Source claim: The association between perioperative beta-blockade and survival tracks baseline risk: benefit appeared at a Revised Cardiac Risk Index of 2 or more, with no benefit and possible harm at a score of 0 or 1.
Perioperative Beta-Blocker Therapy and Mortality after Major Noncardiac Surgery, The New England journal of medicine 2005
recall · CA-2 · phrased by llm
A meta-analysis restricted to the trials of perioperative beta-blockade whose data remain secure pooled outcomes for starting a beta-blocker before noncardiac surgery. State each outcome and its direction, including the mortality figure, and then say what this pooled analysis does not address.
Answer: Pooling only the trials whose data remain secure, starting a beta-blocker before noncardiac surgery increased 30-day all-cause mortality by 27%, increased stroke and hypotension, and reduced non-fatal myocardial infarction. The analysis is about starting a beta-blocker before surgery, so it does not address patients already established on chronic beta-blockade, and it reports pooled outcomes rather than which individual patients should or should not be treated.
Once the insecure trials are removed, the pooled signal for starting a beta-blocker is a 27% increase in 30-day mortality plus more stroke and hypotension, in exchange for fewer non-fatal infarctions.
Source claim: Pooling only the trials whose data remain secure, starting a beta-blocker before noncardiac surgery increased 30-day all-cause mortality by 27%, and increased stroke and hypotension while reducing non-fatal myocardial infarction.
Meta-Analysis of Secure Randomised Controlled Trials of Β-Blockade to Prevent Perioperative Death in Non-Cardiac Surgery, Heart (British Cardiac Society) 2014
recall · CA-3 · phrased by llm
Beta-blocker exposure around major noncardiac surgery was associated with lower ___-day mortality only in patients with two or more Revised Cardiac Risk Index factors, and only in nonvascular surgery.
Answer: 30
Beta-blocker exposure around major noncardiac surgery was associated with lower 30-day mortality only in patients with two or more Revised Cardiac Risk Index factors, and only in nonvascular surgery.
Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery · PMID 23613075
recall · CA-2 · phrased by derived
Long-term preoperative beta-blocker prescription is independently associated with increased postoperative ischaemic stroke risk at 30 and ___ days, especially in lower-risk patients.
Answer: 365
Long-term preoperative beta-blocker prescription is independently associated with increased postoperative ischaemic stroke risk at 30 and 365 days, especially in lower-risk patients.
Beta Blockers, Stroke, and Noncardiac Surgery: Resolving an Enduring Perioperative Dilemma · PMID 42290631
recall · CA-2 · phrased by derived
The point with one number taken out. No model wrote any of this: the stem is the sentence you reviewed, minus a digit, and the paper it came from is named beneath it.
Open prompts
How does your plan change if the patient is not optimised?
open · CA-2 · phrased by derived
What is the physiology behind what we just did?
open · CA-2 · phrased by derived
Talk me through the trade-off you made there.
open · CA-2 · phrased by derived
What would make you abandon this plan and do something else?
open · CA-2 · phrased by derived
Questions only — nothing here asserts anything, which is why a model is allowed to phrase them. Where no model was reachable these are the level defaults.