JOURNAL HOME CME HOME THIS MONTH PAST ISSUES ETOC COLLECTIONS
AUTHORS REVIEWERS EDITORIAL BOARD FEEDBACK RSS HELP
A&A International Anesthesia Research Society
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a colleague
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (29)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by VanDenKerkhof, E. G.
Right arrow Articles by Parlow, J. L.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by VanDenKerkhof, E. G.
Right arrow Articles by Parlow, J. L.
Related Collections
Right arrow Cardiovascular
Right arrow Economics and Health Care Research
Right arrow Surgery

Anesth Analg 2003;96:1558-1565
© 2003 International Anesthesia Research Society

CARDIOVASCULAR ANESTHESIA

Knowledge and Practice Regarding Prophylactic Perioperative Beta Blockade in Patients Undergoing Noncardiac Surgery: A Survey of Canadian Anesthesiologists

Elizabeth G. VanDenKerkhof, RN MSc, DrPH, Brian Milne, MD MSc, FRCPC, and Joel L. Parlow, MD MSc, FRCPC

Department of Anesthesiology, Queen’s University, Kingston General Hospital, Ontario, Canada

Address correspondence and reprint requests to Elizabeth G. VanDenKerkhof, RN, Department of Anesthesiology, Queen’s University, Kingston General Hospital, 76 Stuart St., Kingston, ON K7L 2V7. Address e-mail to ev5{at}post.queensu.ca


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Appendix: Beta Blockers and...
 References
 
A lack of awareness of the "best" current practice is frequently cited as a major barrier to the practice of evidence-based medicine. The purpose of this study was to survey Canadian anesthesiologists to determine their knowledge and practices associated with prophylactic perioperative ß blockade, a therapy that has been widely discussed in the literature and has the potential for a significant positive impact on patient outcomes. We sent questionnaires to 1234 members of the Canadian Anesthesiologists’ Society. The overall response rate was 54%. Ninety-five percent of respondents were aware of the perioperative ß blocker literature, and of these, 93% agreed that ß blockers were beneficial in patients with known coronary artery disease (CAD). Fifty-seven percent reported always or usually administering prophylactic ß blockers in patients with known CAD, and 34% of these regular users continued therapy beyond the early postoperative period. Only 9% of respondents reported that a formal protocol existed at their facility. This study suggests that barriers to the translation of research to practice were not related to a lack of awareness of the current best evidence. With respect to perioperative ß blockers, controversies within the literature as well as practical considerations may be greater barriers to implementation of best evidence.

IMPLICATIONS: This survey found that anesthesiologists were aware of and supported the use of prophylactic perioperative ß blockers in patients with risk factors or known coronary artery disease; however, only 57% frequently prescribed perioperative ß blockers. A lack of awareness of the current "best" evidence was not a barrier to use.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Appendix: Beta Blockers and...
 References
 
The practice of evidence-based medicine has been defined as the integration of individual clinical expertise with the best available external clinical evidence from systematic research (1). Barriers to the practice of evidence-based medicine are identified in the literature as being related to issues of translation and implementation of research to clinical practice. These barriers include the large volume of new studies being published (1–3), the amount of new information required by physicians in their daily practice (4), and the lack of time to adequately filter relevant information from the literature in a timely fashion for use at the point-of-care (1). The purpose of this study was to survey Canadian anesthesiologists to determine their research knowledge and clinical practices associated with perioperative ß blockade, a therapy that has been widely discussed in the literature and has the potential for a significant positive impact on patient outcomes (5–7).

Cardiovascular complications after surgery are common in patients at risk for coronary artery disease (CAD) and represent a major health and economic issue (8,9). Numerous studies have demonstrated perioperative ß blockade to decrease cardiac complications in patients with risk factors or known cardiac disease undergoing noncardiac surgery (5–7,10,11). Although controversies remain in the literature with regard to the efficacy of this therapy (2,12), authorities have published guidelines recommending perioperative ß blockers for patients at risk for cardiac complications who undergo surgery of intermediate or major risk (13–15). The present study was designed to determine the awareness, attitudes, and current practices regarding perioperative ß blockade among Canadian anesthesiologists.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Appendix: Beta Blockers and...
 References
 
After approval from the Queen’s University Research Ethics Board and permission from the Canadian Anesthesiologists’ Society (CAS), the CAS membership list of specialist-trained anesthesiologists was used as the sampling frame for this study (n = 1485). To generate data for a future investigation regarding the feasibility of conducting electronic versus postal surveys, the sample was stratified into three groups, and a random sample was drawn from each group. The three groups consisted of: (a) postal questionnaires sent to anesthesiologists who provided a postal address only to the CAS; (b) postal questionnaires sent to anesthesiologists who provided both postal and e-mail addresses to the CAS; and (c) electronic questionnaires sent to anesthesiologists who provided both postal and e-mail addresses to the CAS.

The primary characteristic of interest used in the sample-size calculation was the proportion of anesthesiologists who always or usually prescribed prophylactic perioperative ß blockers to appropriate patients. Using the probability sampling technique described by Dillman (16), a confidence level of 95%, a sampling error of ±3%, and assuming 50% of the respondents used ß blockers (represents the maximum variation possible), the completed sample size to adequately represent a population of 1485 anesthesiologists is approximately 600. Therefore, 600 anesthesiologists were randomly selected to receive postal questionnaires (300 of the possible 551 anesthesiologists who provided a postal address only and 300 of the possible 934 who provided both postal and e-mail addresses). This latter group was selected to assess if respondents with e-mail addresses registered with the CAS responded differently from respondents without e-mail addresses registered with the CAS. The remaining 634 anesthesiologists who provided both postal and e-mail addresses to the CAS were sent an e-mail containing a cover letter identical to the postal cover letter but with instructions on how to complete the electronic questionnaire and a link to the web page containing an identical electronic version of the questionnaire. Thus, the final sample size consisted of 600 postal questionnaires and 634 electronic questionnaires and represented 83% of specialist-trained anesthesiologists registered with the CAS and working in Canada.

The questionnaire was comprised of 21 items dealing with knowledge, belief, and practices regarding prophylactic perioperative ß blocker administration in patients with risk factors or known CAD (see Appendix). Demographic characteristics, practice characteristics, and information regarding Internet and e-mail use were also included in the questionnaire. Both the paper and the electronic version of the questionnaire were pretested on a group of anesthesiologists in our institution and were designed to take approximately 5 min to complete. The first mailing of both postal and electronic questionnaires took place in November 2001. Invalid electronic addresses were removed from the database after the first mailing. Nonresponders were followed using a modified version of the Dillman technique (16). The electronic group was sent a follow-up email with a link to the questionnaire at 1 wk, 2 wk, and 3 wk after the initial mailing. Nonresponders to the postal questionnaire were sent a follow-up reminder at 6 wk and 12 wk. At 18 wk after the initial mailing, a reminder with a copy of the questionnaire was sent to nonresponders in the postal group. All mailings for both the electronic and the postal arm occurred between November 2001 and March 2002.

All response variables were categorical in nature, and therefore descriptive statistics included frequencies and proportions. Cross-tabulations by questionnaire type were generated for all variables to assess for differences in postal versus electronic responses to determine if the groups could be analyzed together. Statistical significance between groups was assessed using Pearson {chi}2 test and Fisher’s exact test. A significance level of 0.01 was adopted because of the large number of comparisons and the resultant risk of a type I error.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Appendix: Beta Blockers and...
 References
 
The overall response rate for the survey was 54%. Four-hundred-twelve postal responses were returned for a response rate of 69% in the postal group. Fifteen of the postal questionnaires were returned blank with the respondent indicating that perioperative ß blockade was not appropriate for their patient population. Thus, the completed sample size for the postal group was 397. One-hundred-forty-four of the initial electronic surveys were rejected because of invalid addresses, leaving 490 valid participants. One-hundred-seventy-two e-mail questionnaires were returned for a response rate in the e-mail group of 35%. Of these, four indicated that they did not complete the survey because it was not pertinent to their patient population. An additional 14 participants reported login problems, which were subsequently resolved. The final sample size was 168 in the electronic group.

Demographic characteristics of survey respondents stratified by questionnaire type (postal versus e-mail) are shown in Table 1. E-mail respondents were more likely than postal respondents to be affiliated with an academic institution (P = 0.01). Results related to knowledge, beliefs, or practices regarding perioperative ß blockade were not significantly different between postal and electronic questionnaires (results not shown); therefore, these data were analyzed together.


View this table:
[in this window]
[in a new window]
  		Table 1. Demographic Characteristics of Survey Respondents Stratified by Questionnaire Type (postal versus e-mail)
 
Figures 1 and 2A refer to all respondents (n = 534) who indicated that they were aware of the literature on ß blockade therapy, representing 95% of all respondents (Table 2). Ninety-three percent of these respondents strongly or mildly agreed that ß blockers were beneficial in patients with known CAD (Fig. 1). For patients with known CAD, 16% of all respondents who were aware of the literature indicated that they always administered ß blockers, and 41% indicated that they usually administered ß blockers (Fig. 2A). When the analysis included only respondents who strongly agreed that ß blockers were beneficial in patients with known CAD (n = 296), 27% reported always using ß blockers, and 48% reported usually using ß blockers (Fig. 2B).



View larger version (20K):
[in this window]
[in a new window]
  		Figure 1. Responses from 534 anesthesiologists who indicated that they were aware of the perioperative ß blocker literature. Question 2: In your opinion does prophylactic perioperative ß blocker administration in noncardiac patients with risk factors or known coronary artery disease (CAD) have an effect on postoperative outcomes? White columns represent responses regarding patients with known CAD; hatched columns represent responses regarding patients with >=2 risk factors for CAD.

 

View this table:
[in this window]
[in a new window]
  		Table 2. Responses of Canadian Anesthesiologists Regarding Perioperative Beta Blockade (BB) in Patients with Known Coronary Artery Disease (CAD) or Risk Factors for CAD who are Undergoing Noncardiac Surgery
 


View larger version (31K):
[in this window]
[in a new window]
  		Figure 2. Frequency of ß blocker use among anesthesiologists who indicated that they were aware of the ß blocker literature. Data presented represent responses to Question 6: How often do you use prophylactic ß blockers as a routine part of perioperative care in at-risk patients? (A) Data represent all 534 anesthesiologists who indicated awareness of the literature. White columns represent responses regarding patients with known coronary artery disease (CAD); hatched columns represent responses regarding patients with >=2 risk factors for CAD. (B) White columns represent frequency of ß blocker use among 296 anesthesiologists who strongly agreed that perioperative ß blockers have an effect on postoperative outcomes in patients with known CAD; hatched columns represent frequency of ß blocker use among 200 anesthesiologists who strongly agreed that perioperative ß blockers have an effect on postoperative outcomes in patients with >=2 risk factors for CAD.

 
In patients with >=2 risk factors for CAD, 81% of respondents who were aware of the literature strongly or mildly agreed that ß blockers were beneficial (Fig. 1). Ten percent of respondents who were aware of the literature always administered ß blockers, and 31% usually administered ß blockers to patients with risk factors (Fig. 2A). Of the 200 respondents who strongly agreed that ß blockers were beneficial in patients with risk factors, 20% always used ß blockers, and 49% usually used ß blockers (Fig. 2B).

Table 3 presents patterns of ß blocker use for the 347 respondents who indicated that they usually or always prescribed perioperative ß blockers in patients with risk factors or known CAD. Sixty percent of ß blocker users initiated the therapy by prescribing a single dose before surgery, and 25% did not prescribe ß blockers beyond the initial preoperative dose. Only 6.4% continued therapy beyond hospital discharge. The degree of risk of the surgical procedure influenced patterns of ß blocker use (Table 3). Thirty-one percent of ß blocker users indicated that the type of anesthesia (i.e., general versus regional or local) influenced their practice. Metoprolol was the drug of choice for 71% of perioperative ß blocker users. Less than 10% of respondents indicated that there was a formal protocol for prophylactic perioperative ß blocker administration (Table 2).


View this table:
[in this window]
[in a new window]
  		Table 3. Patterns of Use of Perioperative Beta Blockade (BB) by Respondents who Indicated Frequent Use (usually or always) of BB Therapy (n = 347)
 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Appendix: Beta Blockers and...
 References
 
Impact analysis is traditionally measured by the number of times an article is cited in high impact journals. True impact analysis can only be determined by directly examining physicians’ practice. The purpose of this study was to address impact analysis by asking physicians to comment on their research knowledge, beliefs, and clinical practices associated with perioperative ß blockade—a therapy shown to have potential beneficial effects on outcomes in patients with risk factors or known CAD undergoing noncardiac surgery. Ninety-five percent of anesthesiologists reported being aware of the ß blocker literature. This high level of awareness can most likely be attributed to publication of the studies in high impact journals (5–7), the support of leading authorities recommending that the strategy become a standard of care (13,14), and the frequency with which perioperative ß blockade is discussed at conferences. The recent literature continues to support the use of prophylactic perioperative ß blockers in high-risk populations, as evidenced by the updated guidelines published by the American College of Cardiology/American Heart Association (15) and a recent review article (12).

Among anesthesiologists who strongly agreed that prophylactic perioperative ß blockers are beneficial, over 70% frequently prescribed this therapy. On the contrary, this practice was much less frequent among anesthesiologists who did not strongly agree with its efficacy. Thus, roughly half of the respondents overall reported frequent use of ß blockers in surgical patients with risk factors or known CAD. These findings are supported by a recent retrospective chart review where over 60% of general surgery patients who were identified as having definite evidence of or risk factors for CAD were not prescribed ß blockers before surgery (R. Taylor, University of Ottawa, Ontario, personal communication, 2002). With respect to translation, these findings are also consistent with the literature about use of ß blockers after myocardial infarction, where the studies reported that less than half of eligible patients receive therapy (17,18).

Limitations to the wide acceptance of prophylactic ß blocker therapy are related to a number of factors. Controversies in the literature make it difficult to assess the appropriateness of the use of this therapy at the level of clinical practice (19,20). Many of the findings of outcome studies are based on small sample sizes ranging from 26 to 200 patients (12). Issues such as the pharmacokinetic profile of oral, nasogastric, or IV ß blockade administration in surgical patients are not clear in the current literature (5–7,21). Fear of iatrogenic complications are recognized as barriers to research translation (2). In addition, although reducing perioperative stress responses may decrease the postoperative hypercoagulable state, ß blockers do not necessarily prevent this problem (19,20). Physician time constraints have also been identified as barriers to knowledge transfer (1,2). In the case of prophylactic ß blockade, this may be manifested in the difficulty anesthesiologists encounter in closely monitoring patients outside of the immediate perioperative period, where surgeons frequently assume postoperative care and where patients are increasingly scheduled for early discharge.

Hence, research transfer barriers may be due largely to controversies in the perioperative ß blocker literature, leading to confusion surrounding their appropriate use. Whereas clinicians await the results of larger clinical trials, clinical algorithms based on the available literature (12,22) are useful in tailoring treatments to avoid iatrogenic complications. At the institutional level, support can be provided to physicians through the development of protocols based on clinical algorithms. However, more than 90% of respondents in this study reported that no formal protocol existed at their institution.

Limitations of this study include the overall response rate of 54%. Similar to previous studies, the response rate in the electronic questionnaire group was smaller than that in the postal group (23). The response rate of 69% in the postal group is comparable to that reported in the literature for questionnaires of this length (16). Stratification of results pertaining to awareness, beliefs, and practices regarding perioperative ß blockers by either survey method or provision of e-mail address to the CAS determined no difference between these groups. Therefore, an assumption may be made that the combined survey respondents represent the majority of specialty-trained CAS members. The initial sample size calculation was based on a sampling error of ±3%; however, given the completed sample size of 565 and assuming the respondents adequately represent specialty-trained anesthesiologists registered with the CAS, the findings represent the population of 1485 anesthesiologists within a sampling error of ±4%.

It is not certain whether the results can be generalized to all CAS members or to all Canadian anesthesiologists. If one assumes that nonresponders were less likely to be aware of the ß blocker literature or to prescribe perioperative ß blockers, then the true level of awareness would be less than 95%, whereas the proportion using perioperative ß blockers would be less than 50%. In addition, only about half of Canada’s anesthesiologists are CAS members. A large proportion of respondents were affiliated with an academic institution (63%). It is likely that the level of continuing education among respondents differs from the population of anesthesiologists as a whole. A further limitation of this study is that the 60% of respondents who provided only a single dose of ß blocker before surgery were not asked if other providers, such as the surgical service, were likely to continue the therapy after surgery. The likelihood of this having an impact on the provision of perioperative ß blockers is minimal, given that only 21% of respondents indicated that surgeons were actively involved in the provision of ß blocker therapy. Finally, respondents were asked to recall and characterize ß blocker practice patterns, which may have led to recall bias in the responses. Therefore, the validity of these results cannot be established without performing extensive multicenter chart audits, which is beyond the scope of this study. A strength of this study is that physicians were asked directly to report on their awareness and practices regarding the findings of studies published in high impact journals rather than relying on more indirect measures such as the impact factor to assess impact of research on practice.

The findings of this survey indicate that whereas the anesthesiologists surveyed were aware of the evidence published in high impact journals regarding the benefits of ß blocker therapy, many had not transferred this knowledge to their practice. These findings do not support the theory that a major barrier to the translation of knowledge from research to practice was largely because of a lack of awareness of the current best evidence. With respect to perioperative ß blockers, controversies in the literature as well as practical considerations may be larger barriers to implementation of best evidence.


   Appendix: Beta Blockers and Surgical Outcomes
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix: Beta Blockers and...
References
 


View this table:
[in this window]
[in a new window]
 
 

   Acknowledgments
 
Supported, in part, by the Queen’s University Advisory Research Committee.

We would like to thank Dr. Seal and the CAS members who participated in the survey. We would also like to acknowledge the personnel support provided by the Queen’s University Department of Anesthesiology and the contributions made by Nicole Avery, Beth Orr, Debbie Tod, Charlotte Lee, Jeff Babcock, and Mike Rimmer.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix: Beta Blockers and...
 References
 

  1. Sackett DL, Richardson WS, Schleyer TK, Haynes RB. Evidence-based medicine: how to practice & teach EBM. Edinburgh: Churchill Livingstone, 1998.
  2. Rich MW. From clinical trials to clinical practice: bridging the GAP. JAMA 2002; 287: 1321–3.[Free Full Text]
  3. Davidoff F, Haynes B, Sackett D, Smith R. Evidence based medicine. BMJ 1995; 310: 1085–6.[Free Full Text]
  4. Covell DG, Uman GC, Manning PR. Information needs in office practice: are they being met? Ann Intern Med 1985; 103: 596–9.
  5. Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery: Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med 1996; 335: 1713–20.[Abstract/Free Full Text]
  6. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery: Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 1999; 341: 1789–94.[Abstract/Free Full Text]
  7. Wallace A, Layug B, Tateo I, et al. Prophylactic atenolol reduces postoperative myocardial ischemia: McSPI Research Group. Anesthesiology 1998; 88: 7–17.[Web of Science][Medline]
  8. Mangano DT. Perioperative cardiac morbidity. Anesthesiology 1990; 72: 153–84.[Web of Science][Medline]
  9. Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med 1995; 333: 1750–6.[Free Full Text]
  10. Boersma E, Poldermans D, Bax JJ, et al. Predictors of cardiac events after major vascular surgery: role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. JAMA 2001; 285: 1865–73.[Abstract/Free Full Text]
  11. Stone JG, Foex P, Sear JW, et al. Myocardial ischemia in untreated hypertensive patients: effect of a single small oral dose of a beta-adrenergic blocking agent. Anesthesiology 1988; 68: 495–500.[Web of Science][Medline]
  12. Auerbach AD, Goldman L. Beta-blockers and reduction of cardiac events in noncardiac surgery: scientific review. JAMA 2002; 287: 1435–44.[Abstract/Free Full Text]
  13. Palda VA, Detsky AS. Perioperative assessment and management of risk from coronary artery disease. Ann Intern Med 1997; 127: 313–28.[Abstract/Free Full Text]
  14. Guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major noncardiac surgery: American College of Physicians. Ann Intern Med 1997; 127: 309–12.[Free Full Text]
  15. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery: executive summary a report of the Am College of Cardiology/Am Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2002; 105: 1257–67.[Free Full Text]
  16. Dillman D. Mail and internet surveys: the tailored design method. 2nd ed. New York: John Wiley & Sons, Inc, 2000.
  17. Freemantle N, Cleland J, Young P, et al. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ 1999; 318: 1730–7.[Abstract/Free Full Text]
  18. Viskin S, Barron HV. Beta blockers prevent cardiac death following a myocardial infarction: so why are so many infarct survivors discharged without beta blockers? Am J Cardiol 1996; 78: 821–2.[Web of Science][Medline]
  19. Sear JW, Foex P, Howell SJ. Effect of chronic intercurrent medication with beta-adrenoceptor blockade or calcium channel entry blockade on postoperative silent myocardial ischaemia. Br J Anaesth 2000; 84: 311–5.[Abstract/Free Full Text]
  20. Sprung J, Abdelmalak B, Gottlieb A, et al. Analysis of risk factors for myocardial infarction and cardiac mortality after major vascular surgery. Anesthesiology 2000; 93: 129–40.[Web of Science][Medline]
  21. Zaugg M, Tagliente T, Lucchinetti E, et al. Beneficial effects from beta-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology 1999; 91: 1674–86.[Web of Science][Medline]
  22. Auerbach AD, Goldman L. Beta-blockers and reduction of cardiac events in noncardiac surgery: clinical applications. JAMA 2002; 287: 1445–7.[Abstract/Free Full Text]
  23. Mavis BE, Brocato JJ. Postal surveys versus electronic mail surveys: the tortoise and the hare revisited. Eval Health Prof 1998; 21: 395–408.[Abstract/Free Full Text]
Accepted for publication January 14, 2003.




This article has been cited by other articles:


Home page
 Br J AnaesthHome page
S. Suttner, J. Boldt, A. Mengistu, K. Lang, and J. Mayer
Influence of continuous perioperative beta-blockade in combination with phosphodiesterase inhibition on haemodynamics and myocardial ischaemia in high-risk vascular surgery patients
Br. J. Anaesth., May 1, 2009; 102(5): 597 - 607.
[Abstract] [Full Text] [PDF]

Home page
 Eval Health ProfHome page
S. Sussman, T. W. Valente, L. A. Rohrbach, S. Skara, and M. Ann Pentz
Translation in the Health Professions: Converting Science into Action
Eval Health Prof, March 1, 2006; 29(1): 7 - 32.
[Abstract] [PDF]

Home page
 SEMIN CARDIOTHORAC VASC ANESTHHome page
M. J. London
Beta-Blockade in the Perioperative Period: Where Do We Stand After All the Trials?
Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2006; 10(1): 17 - 23.
[Abstract] [PDF]

Home page
 BMJHome page
D. Redelmeier, D. Scales, and A. Kopp
{beta} blockers for elective surgery in elderly patients: population based, retrospective cohort study
BMJ, October 22, 2005; 331(7522): 932.
[Abstract] [Full Text] [PDF]

Home page
 Anesth. Analg.Home page
M. J. Jacka, T. Schricker, B. Warriner, A. Boulton, R. Hudson, J. L. Parlow, B. Milne, and E. G. VanDenKerkhof
More Conclusive Large-Scale Trials Necessary Before Recommending Use of Beta Blockade in Patients at Risk * Response
Anesth. Analg., January 1, 2004; 98(1): 269 - 270.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a colleague
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (29)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by VanDenKerkhof, E. G.
Right arrow Articles by Parlow, J. L.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by VanDenKerkhof, E. G.
Right arrow Articles by Parlow, J. L.
Related Collections
Right arrow Cardiovascular
Right arrow Economics and Health Care Research
Right arrow Surgery

Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press