Preoperative β-Blockers for Isolated Coronary Artery Bypass Graft: Does the Evidence Cited by the Current Quality Measures Support Them?
Year: 2018
Type: article
Abstract: β -Blocker administration ≤24 hours before isolated coronary artery bypass graft (CABG) surgery has been a National Quality Forum (NQF)-endorsed quality measure since 2007.The American College of Cardiology Foundation/ American Heart Association CABG guidelines list this as a class I recommendation, whereas the European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines recommend β-blockers to prevent postoperative atrial fibrillation (AF) without specifying a time frame.The primary rationale for pre-CABG β-blocker administration expressed in the NQF measures and guidelines is preventing postoperative AF; the NQF measures also broach reduced mortality.Postoperative AF is associated with increased morbidity, length of stay and hospital costs, and significantly poorer survival 1 ; the expectation is that preventing AF prevents or mitigates these outcomes.Two NQF-endorsed versions of the 24-hours-prior-to-incision quality measure exist: Measure 0127 draws on the Society of Thoracic Surgeons Adult Cardiac Surgery Database, forming part of the Receipt of Required Perioperative Medications in publicly reported Society of Thoracic Surgeons CABG composite scores for cardiac surgery groups and hospitals; Measure 0236 draws on Medicare claims data and is used in the Merit-Based Incentive Payment System, which, by 2022, places 9% of participating physicians' Medicare reimbursement at risk, depending on performance.It is critical that process measures in such programs be firmly grounded in evidence.Recent studies question the benefits of preoperative β-blockers in CABG.[2][3][4] We reviewed the evidence cited by the quality measures and guidelines.Full text for the studies cited in the rationales underlying NQF measures 0127 and 0236, or by the 2014 European Society of Cardiology/European Association for Cardio-Thoracic Surgery and 2011 American College of Cardiology Foundation/American Heart Association guidelines recommending β-blockers to prevent post-CABG AF, was obtained.For Measure 0127, we used the 2013 rather than 2016 supporting documents because they cited specific studies, whereas the 2016 update referenced only the 2011 American College of Cardiology Foundation/ American Heart Association guidelines.We reviewed the cited articles, collecting data on study type, population, timing of β-blocker administration, and outcomes examined to determine applicability to the specifics of the β-blocker administration within 24 hours before surgical incision in isolated CABG patients measure/recommendation.We used only published data and did not require institutional review board approval.Altogether, 22 supporting studies (Table ) were cited: 8 meta-analyses, 6 randomized controlled trials, 7 observational studies, and 1 review article.Only 2 meta-analyses differentiated between preoperative, intraoperative, and postoperative β-blockers, and none looked at isolated CABG separately from other cardiac surgeries, despite varying risks for postoperative AF.The randomized controlled trials showed similar difficulties: whereas most focused on isolated CABG, 3 looked
Language: English
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2905443268