Non-cardiologist Physicians Research Articles

Cardiovascular Imaging in Women with Heart Diseases, A local Clinical Practice Guidelines for Pakistani Population

This is the first time that a local preliminary document on gender differences in CVDs has been initiated in Pakistan. International forum has been highlighting significant gender and ethnicity in CVDs. So different countries from world took the initiative to develop their local guideline or clinical scientific statements on gender differences with different socio-cultural and educational background for their own countries. GRFW in collaboration with Scientific Council of Women with Heart Disease PCS Pakistan floated this idea to develop a local guideline in various aspects CVDs for our own women population. In this regard different topics were assigned to different groups including mostly female cardiologists, senior gynecologists/obstetricians and radiologist from all over Pakistan. Primary objectives of this write up on Cardiac Imaging in Women is to provide a local clinical practice guideline for the assessment and management of CVD that will improve and standardize the physicians’ decision making for Pakistani women population. In the setting of growing awareness of providing personalized precision medicine, addressing sex differences in CVD is a key goal. The intention is to inform cardiologists, non-cardiologist physicians’, general practitioners, and, obstetrician/gynecologists about the reasonable use and understanding of technologies to help in proper approach to their treating women with HDs and when to send them for cardiac specialist diagnostic center. As we could not find our own local data on cardiac imaging to report at present, most recommendations on cardiac imaging used has been taken from international literatures (which we have found feasible, readily available, and some cost effective approach in our money constraint society which can be followed in our population) and also which were published within the past decade were given priority. In this document, we discuss the role of using different cardiac imaging modalities, with a focus on diseases which are unique/or occur more in women. So, five women specific topics more commonly seen in our population were selected currently, which are (stable/unstable angina and ACS, MINOCA), non-ischemic CMP, HD during pregnancy, cardio-oncology, and connective tissue diseases (CTD). In these topics we have tried to used our own local incidences and prevalence of these diseases in our community/internationally on gender basis and have highlighted the availability/limitations of cardiac imaging in our society. The updated recommendations in women have been taken from international guidelines. Graphs and tables layout has been taken from abroad literatures and made some few changes according to its use in our population. You will find this a preliminary review document which will be simple to read, have updated approach in evaluating the diagnosis of HD in women easily. For current cost effectiveness issues for our population will be taken up by PCS to Health ministries of Pakistan for its making it easily availability with cheap cost so to benefit our female (very neglected and ill informed) with CVD population.

A Critical Evaluation of Patient Pathways and Missed Opportunities in Treatment for Heart Failure.

Heart failure (HF) is a global problem responsible for significant morbidity and mortality. This review describes the patient pathways and missed opportunities related to treatment for patients with HF. The contemporary management strategies in HF, including medical therapies, device therapy, transplant, and palliative care. Despite the strong evidence base for therapies that improve prognosis and symptoms, there remains a large number of patients that are not optimally managed. The treatment of patients with HF is highly influenced by those who are caring for them and varies widely across geographical regions. HF patients can be broadly classified into two key groups: those who have known HF, and those who are incidentally found to have reduced left ventricular systolic dysfunction or other cardiac abnormality when an echocardiogram is performed. While all patients are under the care of a general practitioner or family doctor, in other instances, non-cardiologist physicians, cardiologists, and specialist HF nurses-each will have varying levels of expertise in managing HF-are part of the broader team involved in the specialist management of patients with HF. There are many potential missed opportunities in HF treatment, which include general opportunities, medications, etiology-specific therapy, device therapy, therapies when initial treatments fail, and palliative care.

P0575 / #368: HEMODYNAMIC EVALUATION GUIDED BY ECOGRAPHY AND MONITORING OF OXYGEN EXTRACTION IN PEDIATRIC SEVERE SEPSIS

Aims & Objectives: Verify the dynamics of tissue oxygenation and observe the hemodynamic variables as recommended in guidelines for monitoring. Methods: It is a cohort with 32 patients of 29 days to 16 years in the PICU in a university hospital in Brazil, who had severe sepsis classification and the need for invasive mechanical ventilation (IVM). The hemodynamics variables: CI, SVRI, ScvO2, CVP, ΔPCO2, inferior vena cava distensibility index (ΔIDVCI), lactate, qualitative and quantitative left ventricular dysfunction and qualitative right ventricular dysfunction. The oxygen variables: DO2I, VO2I, go2ER. The measures were initial IVM, 6a, 12a, 24h and after, once a day until the 7th day of ventilation. A single non-cardiologist physician performed all examinations. We considered the gold standard to hemodynamic dysfunction, CI lower 3.3 L /min/m2. For all tests including 95% CIs. Results: There was a balance between the DO2I and VO2I maintaining a good go2ER since we didn’t have significant hyperlactatemia. A correlation was observed between qualitative right ventricular dysfunction and a decrease in the ΔIDVCI. We observed an inverse relationship between CVP and ΔIDVCI (p < 0,001). There wasn’t a correlation between ΔPCO2 and CI (p > 0,05). Findings from the physical examination were mostly more specific than sensitive (AC 50.0 % at 84.2%). Findings from the qualitative echocardiographic were also more often than not specific than sensitive (AC 65.6 % at 89.3%). Conclusions: Oxygenation surveillance and the use of echocardiography by a non-cardiologist proved to be possible tools to be incorporated into the clinical practice of critically ill patients.

Electrical storm 11\u2009days after acute myocardial infarction: a case report

BackgroundThe definition of electrical storm is still debated. For example, an electrical storm is defined as a clustering of three or more separate episodes of ventricular tachycardia/ventricular fibrillation within 24 hours or one or more episodes occurring within 5 minutes of termination of the previous episode of ventricular tachycardia/ventricular fibrillation. When it is refractory to medications, prompt assessments by coronary angiography, sedation, and overdrive pacing should be performed. An electrical storm may occur anytime, including at night or after the patient leaves an intensive care unit.Case presentationA 70-year-old Japanese man with type 2 diabetes mellitus was diagnosed as having ST-elevation myocardial infarction. His clinical course after an urgent percutaneous coronary intervention was uneventful, but he developed electrical storm that was refractory to antiarrhythmic medications on day 11 of hospitalization. We used sedative medications and performed ventricular overdrive pacing and transferred him to a university hospital for further treatment, which included electrical ablation and cardioverter-defibrillator implantation.ConclusionAn electrical storm is a relatively rare and fatal complication of acute myocardial infarction. It is important that the treatment choices for this condition are known by non-cardiologist physicians who might encounter this rare condition.

Cardiac Ultrasound in the Intensive Care Unit: A Review.

Transthoracic echocardiography (TTE) is an incredibly valuable tool in today’s emergency rooms and intensive care units (ICUs). It has the ability to provide a complete evaluation of the structure and function of the heart, the valves, stroke volume, ejection fraction, and much more. Previous academic studies have also determined that point-of-care TTE done by non-cardiologist physicians can also provide higher accuracy in patient assessment and management, with potential prognostic impact by assessing the severity of cardiac dysfunction and response to treatment. The aim of this review article is to examine further these point-of-care evaluations, what they entail, their benefits, and where further research would better our own understanding.

EVOLUTION OF EKG READING SKILLS FROM MEDICAL SCHOOL TO RESIDENCY

Studies rate non-cardiologist physicians an accuracy of 36% to 96% in detecting ECG abnormalities. The objective of this study is to gain insights into level-based competency and level of comfort among trainees in various disciplines: medical students and residents in internal medicine (IM),

Point-of-care and lung ultrasound incorporated in daily practice

Point-of-care ultrasound (POCUS) is a fast-growing clinical utility and is becoming an essential clinical skill for all practitioners attending to critically ill patients. Ultrasound equipment is now smaller, more affordable and readily available in clinical work areas. POCUS is performed by a non-cardiologist physician at the patient’s bedside as an adjunct to the physical examination. It is easily taught, non-invasive and allows for real-time clinical information. Bedside use of ultrasound imaging aids with rapid diagnosis of severe and life-threatening pathological conditions. It can be repeated, may change clinical management, and impact on patient outcome. POCUS has a broad clinical use, including, but not limited to, focused assessed transthoracic echocardiography (FATE), lung ultrasound imaging, extended focused assessment with sonography for trauma (e-FAST), vascular access and regional blocks. It may also be extended to detect endotracheal intubation and the estimation of intracranial pressure. Assessment of cardiac pathology by POCUS, performed by a novice examiner, has been shown to compare with the gold standard of an expert. Training is paramount. The physician should know his limitations and always relate the information back to the clinical scenario and context. By incorporating POCUS as part of our armamentarium and into our daily medical practice, we might see it reach its full clinical potential, optimising patient care and improving patient outcomes.

The Translation of Knowledge Into Practice in the Management of Atrial Fibrillation in Singapore

Atrial fibrillation (AF) is a clinically significant cardiac arrhythmia known to increase the risk of stroke by at least four times. Stroke-risk assessment and thromboprophylaxis are vital components in AF management. Guidelines are available to standardise AF management, but physicians' adherence to the recommended guidelines has been low. The aims were to: 1. Examine and compare the level of knowledge and current practice in AF management between cardiologists and non-cardiologist physicians in Singapore; 2. Identify physicians' perceived barriers to prescribing oral anticoagulants (OACs) when indicated; 3. Identify strategies to optimise AF management. From June 2017 to August 2017, a cross-sectional online survey involving physicians was conducted in Singapore. The survey instrument was adapted from a previously developed instrument, and validated locally by five cardiologists. It explored the physicians' stroke-risk assessment practices, estimation of stroke risk and benefits of anticoagulation, likelihood of prescribing anticoagulation when indicated, perceived barriers to anticoagulation, and strategies to optimise AF management. Sixty-three (63) physicians completed the survey (14 cardiologists and 49 non-cardiologist physicians). No significant difference was found between cardiologists and non-cardiologist physicians in their assessment and estimation of stroke risk for stable AF patients. However, when presented with an AF patient with stroke risk, cardiologists were more likely than non-cardiologist physicians to prescribe novel OACs (93% vs. 51%; χ2=7.933, p=0.004). Compared to cardiologists, the majority of the non-cardiologist physicians thought the risk of falls were usually or always barriers to prescribing OACs (29% vs 69%; χ2=7.579, p=0.006). Among the suggested strategies to support them in AF management, physicians have overwhelmingly rated two as "quite useful" and "very useful": the establishment of clinics for monitoring anticoagulated patients (100%); and involvement of pharmacists in managing patients on warfarin (98.4%). Physicians possess good knowledge about stroke-risk assessment in AF patients yet it is not translated into effective measures for stroke prevention. Physicians, especially non-cardiologist ones, were not anticoagulating AF patients when indicated. Although novel OACs are safer alternatives to warfarin, non-cardiologist physicians were less inclined to use them for stroke prevention. All physicians opined that establishing anticoagulation clinics and collaborating with pharmacists were useful strategies to optimise AF management. Existing barriers to anticoagulation impeded the translation of knowledge into practice in the management of AF patients in Singapore, for which optimal strategies to optimise AF management are ascertained.

Use of focus assessed transthoracic echocardiography (FATE) in the veterinary emergency room

ABSTRACT: The use of bedside focus assessed transthoracic echocardiography (FATE) is widespread in human medicine, and the potential for veterinary medicine has only recently been investigated. Focused echocardiographic examination can be beneficial in critically ill patients compared to other bedside diagnostic methods, as well as facilitating rapid therapeutic approaches in the emergency room. The aim of this review is to discuss FATE and identify its main applications in veterinary medicine. In this context, FATE has proved to be benefical even when carried out by a non-cardiologist physician or veterinarian. However, a few references on this subject exist in the veterinary literature and there is still a need for standardization of this technique for use in animals.

Why Anesthesiologists Must Incorporate Focused Cardiac Ultrasound Into Daily Practice.

The size, availability, cost, and quality of modern ultrasound devices have, for the first time in modern medicine, enabled point-of-care ultrasound by the noncardiologist physician. The appropriate application of focused cardiac ultrasound (FoCUS) by anesthesiologists has the potential to alter management and affect outcomes for a wide range of patients. In this article, the indications, benefits, and limitations of FoCUS are described. The training and equipment required to perform FoCUS are also discussed.

Early Screening for Cardiovascular Abnormalities With Preparticipation Echocardiography

The traditional history and physical (H&P) is a poor screening modality to identify athletes at risk for sudden cardiac death (SCD). Although better than H&P alone, electrocardiograms (ECG) have also been found to have high false positive rates. Portable echocardiogram by a non-cardiologist (PENC) physician done during preparticipation evaluation (PPE) allows for direct measurements of the heart to more accurately identify patients with structural abnormalities that can result in SCD. Therefore, it is worthwhile to assess the feasibility of PENC as part of PPEs. PURPOSE: To investigate the feasibility of incorporating PENC into routine PPEs. METHODS: Thirty-five Division I male college athletes were prospectively enrolled in the study after informed consent was obtained. Each athlete underwent a screening H&P, ECG, and PENC. The H&P was based on the 12-element preparticipation cardiovascular screening guidelines from the American Heart Association. The ECGs were interpreted using the 2010 European Society of Cardiology criteria. The PENC measurements were obtained in the parasternal long-axis view. End-diastolic measurements were recorded of the left ventricular (LV) diameter, LV posterior wall thickness, interventricular septal wall thickness, aortic root diameter, and ascending aorta. The length of time for screening at each station was recorded and reported in seconds (sec). A paired t-test with alpha level of <0.5 was used to compare length of time (mean ± standard deviation) of each screening method. RESULTS: Six athletes had a positive finding in H&P screening and four athletes had positive ECG findings. One athlete had both a positive H&P and screening ECG. All athletes had negative PENC screens. All four athletes with positive ECG findings have been referred for formal evaluation with cardiology_outcome of cardiology referrals pending. The length of time for screening was significantly shorter with PENC (137.7 ± 40.4 sec) compared with H&P (244.2 ± 80.0 sec) and ECG (244.9 ± 85.6 sec, P<0.01). The screening time did not differ between H&P and ECG (P=.97). CONCLUSION: Incorporating PENC into PPEs has the potential to limit the number of false positive cardiac screens. PENC was the fastest screening modality compared with traditional H&P and ECG methods and can feasibly be incorporated into PPE screening.

Physician Volume, Specialty, and Outcomes of Care for Patients With Heart Failure

There is an urgent need to improve outcomes and reduce costs for patients with heart failure (HF). Physician volume is associated with better outcomes for patients undergoing procedures, but its association with outcomes for medically managed diseases, such as HF, is not well understood. We used Medicare inpatient data in 2009 to examine all HF admissions to acute care hospitals in the United States. We divided physicians into quintiles according to their volume of patients with HF. We used patient-level regression to compare 30-day risk-adjusted mortality, readmissions, and costs across volume groups, controlling for patient, physician, and hospital characteristics. We examined physician volume within strata of hospital volume and physician specialty. Patients cared for by the high-volume physicians had lower mortality than those by the low-volume physicians (8.9% versus 9.7%; P<0.001); this relationship was strongest in low-volume hospitals. In contrast, patients cared for by high-volume physicians had higher readmission rates (25.8% versus 21.5%; P<0001); this relationship was similar across hospital volume groups. Finally, costs were higher for the high-volume physicians ($8982 versus $8731; P=0.002, a difference that was consistent across hospital volume groups). The relationship between physician volume and mortality was strongest for internists (9.2% versus 10.6%; P<0.001) and weakest for cardiologists (6.4% versus 6.7%; P=0.485). Physician volume is associated with lower mortality for HF, particularly in low-volume institutions and among noncardiologist physicians. Our findings suggest that clinician expertise may play an important role in HF care.

Indications, Utility and Appropriateness of Echocardiography in Outpatient Cardiology.

Objective:Respect of “appropriateness” is considered an essential requirement, both on the clinical and the economic profile, and also as it helps to shorten the waiting list. However, only a few studies have dealt with the control of appropriateness in clinical practice, and most of them have focused only on hospital admissions and invasive procedures.Materials and Methods:INDICARD-out is a prospective, multicenter study carried out by A.R.C.A. (Associazioni Regionali Cardiologi Ambulatoriali) cardiologists from 13 Italian Regions, providing information on indications, utility and appropriateness of echocardiography in outpatient cardiology.Results:A total of 2110 prescriptions for echocardiogram were evaluated. Hypertension (23%) and the screening of asymptomatic subjects (17%) by far were the most frequent indications to echocardiography. Overall, 54% of the tests resulted appropriate, 30% were of uncertain appropriateness and 16% were inappropriate. Besides, 31% of the echocardiograms were not useful, and 28% were non pertinent for patient management. The vast majority of prescriptions (72%) came from non-cardiologist physicians (54% from general practitioners). The echocardiograms prescribed by cardiologists were significantly more appropriate, more useful and more pertinent than the tests prescribed by non-cardiologists.Conclusions:The appropriateness, utility and pertinence of the echocardiography are still suboptimal in practice cardiology, especially when indicated by non-cardiologists. The cardiologist, from mere executor of tests prescribed and managed by other physicians, should gain the role of the clinician who takes care of all the cardiologic needs of the patient community.

Echocardiography by the non-cardiologist: a curriculum for the fast track strategy.

A formal echocardiographic approach in a general intensive care unit requires a 24 hour availability of an expert in echocardiography, who could not be easily found. Therefore, a goal-directed echocardiogram strategy specifically tailored to the intensivist should be created. The concept of goal-directed echocardiography (GDE) has been incompletely evaluated and it is necessary to find a curriculum program to grant proficiency. We propose the Fast-Track Echocardiographic Strategy (FTES) program to accomplish both objectives. All medical associations of echocardiography agree that extensive training and experience are needed to acquire and interpret a formal echocardiogram, however, to answer the five questions of FTES a simpler curriculum program would be enough. The aim of this review study was to propose a curriculum to teach non-cardiologist physicians intensivist (NCPI) to use a GDE such as FTES. A search for published literature, from 1999 until June 2008, in English and French languages in Medline was undertaken in order to find out the most relevant and contemporary studies in this area. Strength of evidence of the articles found was based on five strengths of evidence. A framework for published medical research's critical appraisal and a checklist for sources of bias were used for assessment of studies quality. In overall, all studies showed it was possible to teach NCPI to use a GDE examination. After a critical appraisal of the literature, we proposed FTES program to grant proficiency to NCPI in a GDE, to be used in hemodynamic unstable critically ill patients (hypotension with or without hypoxemia), to answer five simple questions, in order to define an hemodynamic profile and consequently be able to optimize their treatments. In conclusion, probably FTES program should at least be considered.

Echocardiography in low-resource rural tropical hospitals

Cardiopathies are common in tropical regions and echocardiography could be of substantial value. However, it is difficult to practice. We suggest simple techniques with conventional instruments that are available in many rural hospitals, and describe the most common echocardiographic procedures and findings that can be undertaken with short training by non-cardiologist physicians.

Cardiovascular Risk Screening Before Starting Stimulant Medications and Prescribing Practices of Canadian Physicians: Impact of the Health Canada Advisory

In May 2006, Health Canada released a statement advising against the use of stimulant medications for patients with cardiac disease after isolated reports of sudden death. The objectives of this study were to determine whether the Health Canada advisory has had an impact on cardiovascular screening of all children with attention-deficit/hyperactivity disorder before stimulants and the medical treatment of children with attention-deficit/hyperactivity disorder and real or potential cardiac problems. Two questionnaires were developed and mailed to a sample of noncardiologist physicians and pediatric cardiologists in Canada. The difference in the proportion of noncardiologist-responders who performed a "full screen" before and after the announcement of the Health Canada advisory was analyzed. Willingness to prescribe stimulant medications to children was assessed by using a series of clinical scenarios. A total of 2326 questionnaires were distributed, 717 (31%) of which were returned. The proportion who performed a full screen increased for both noncardiologists and cardiologists after the advisory. There was also a dramatic increase in the use of the "modified screen" by the noncardiologist group and the pediatrician subgroup. There was a considerable decrease in the proportion of noncardiologists who were willing to prescribe stimulant medications to children with potential or actual cardiac issues after the advisory. The Health Canada advisory has had an impact on clinical practice. It has resulted in an increase in the use of cardiovascular assessment tools before starting stimulants and a decrease in noncardiologists' willingness to prescribe stimulants to those with real or potential cardiac disease. These changes have occurred despite the lack of studies to address the cardiac risks of these medications. Because it will be difficult to assess the true cardiac risks of stimulants, consensus recommendations are needed to determine whether screening is required, what constitutes an appropriate screen, and which children can be treated cautiously with stimulant medications.

Interpretation of the electrocardiogram: clinical correlation suggested

Vijayaraghavan et al. have investigated the interpretation of the initial 12-lead electrocardiogram (ECG) in acute coronary syndrome (ACS) patients, focusing on the patient with potential ST segment elevation myocardial infarction (STEMI).1 The authors emphasize the importance of accurate ECG interpretation by the acute care physician (i.e. emergency physician, internist, and cardiologist).1 The authors compared the initial interpretation of the initial admission ECG by the treating physician with the interpretation of the same tracing by a physician at the core electrocardiographic laboratory. The ECG interpreters at the site were acute care physicians (emergency physician, internist, and cardiologist); at the core lab, the ECG was interpreted by non-cardiologist physicians using specific definitions of abnormality—in this case, ST segment elevation was defined as >0.1 mV in two contiguous leads. The subgroup of patients used in the study were taken from the Canadian ACS Registry and comprised 1310 patients, of which 1202 had complete data and were used for analysis. The definition of STEMI included ST segment elevation and a positive biomarker. What is unclear is whether a positive biomarker was a single spot test or the more appropriate ‘typical rise and fall’ pattern. Overall concordance between core-lab and site interpretation of the admission ECG was 62%. The calculated kappa value was 0.49, indicating modest agreement. When compared with the agreement group of the study, patients in the discordant subgroup were older with higher rates of diabetes mellitus, angina, myocardial infarction, congestive heart failure, coronary artery bypass grafting, and percutaneous coronary intervention. Patients with core-lab-defined ST segment elevation that was not noted by the treating site, who also had a positive biomarker, were significantly less likely to receive aspirin, heparin, and reperfusion therapy when compared with patients with core lab-site ECG interpretation agreement. After adjusting for other validated prognostic factors, site-unrecognized ST … *Corresponding author: Tel: +1 4344651816, Fax: +1 4349242877. Email: wb4z{at}hscmail.mcc.virginia.edu

Level of practice for ECG interpretation skills should be ‘expert’

Level of practice for ECG interpretation skills should be ‘expert’

Warfarin Prescribing in Atrial Fibrillation: The Impact of Physician, Patient, and Hospital Characteristics

Purpose The study investigated the determinants of warfarin use in patients with atrial fibrillation (AF). Methods We assembled a retrospective cohort of community-dwelling elderly patients (aged ≥66 years) with AF using linked administrative databases. We identified the physicians responsible for the ambulatory care of these patients using physician service claims and compared patients who did and did not have an identifiable provider. For those patients with an identifiable provider, we assessed the association between patient, physician, and hospital factors and warfarin use. Results Our cohort consisted of 140,185 patients, of whom 116,200 (83%) had an identifiable cardiac provider. Patients without a provider were significantly more likely to have comorbid conditions that increase their risk of warfarin-associated bleeding. After adjustment for clinical factors, patients without a provider were significantly less likely to receive warfarin (odds ratio 0.37, 95% confidence interval: 0.36-0.38). Of patients with providers, 50,551 patients (43.5%) received warfarin within 180 days after hospital discharge. Warfarin use was positively associated with AF-associated stroke risk factors (eg, prior stroke, congestive heart failure) and negatively associated with warfarin-associated bleeding risk factors (eg, history of intracerebral hemorrhage). After controlling for patient and hospital factors, patients cared for by noncardiologist physicians with cardiology consultation were more likely to receive warfarin then patients treated in noncollaborative environments. Conclusions Warfarin continues to be substantially underprescribed to patients who are at high risk for AF-associated cardioembolic stroke. Our findings highlight the need for targeted quality improvement interventions and suggest preferred models of AF care involving routine collaboration between cardiologists and other physicians.

Lack of Physician Concordance With Guidelines on the Perioperative Use of β-Blockers

The American College of Physicians recommends perioperative use of beta-blockers for certain patients to improve outcomes after surgery. Study of physician behavior with respect to guidelines and recommended practices have shown that beta-blockers have been underutilized after myocardial infarction. We evaluated physician concordance with the perioperative use of beta-blockers along with a specialty-related difference in the frequency of perioperative beta-blocker use. To determine perioperative use of beta-blockers, we retrospectively analyzed the medical charts of adult patients who underwent open cholecystectomy at a tertiary care medical center from December 1997 through December 2001. Patients met criteria for perioperative beta-blocker use if they had a history of coronary artery disease or if they had the presence of 2 or more of the following risk factors: 65 years or older; history of hypertension, diabetes mellitus, or hypercholesterolemia; or current smoking. Among the 336 cases of cholecystectomy reviewed, criteria for beta-blocker use were met in 146 patients (43%) who did not have emergency operations and/or contraindications to beta-blocker use. Of these 146 patients, 123 (84%) had a documented preoperative medical evaluation by a physician in the medical chart. There were 44 patients (30%) receiving beta-blockers prior to admission, and 102 patients (70%) were not receiving beta-blockers. Of those 102 patients not receiving beta-blockers at admission but who meet criteria for their use, 94 (92%) were not started on beta-blocker therapy preoperatively. Of the 18 patients evaluated by a cardiologist, 4 (22%) were started on beta-blocker therapy compared with 3 (6%) of 47 patients evaluated by a noncardiologist physician (P =.08). Perioperative beta-blocker therapy is underutilized in patients with risk factors for coronary artery disease despite evidence that its use in appropriate individuals may be lifesaving.