Decision support only. Not medical advice. Consult a licensed clinician before initiating or changing therapy.

Patient 018

55y·male·white·ASCVD 9.5%

2 active reversal flags

  1. Perioperative MedicineHigh

    Perioperative beta-blockers for noncardiac surgery

    Why flagged

    Beta-blocker-naive patient scheduled for noncardiac surgery; acute initiation reversed by POISE 2008 (doubled stroke risk HR 2.17, increased all-cause mortality).

    1. Prior guidance2008

      Routine, acute initiation of beta-blockers immediately prior to noncardiac surgery in patients at risk for cardiovascular events to prevent perioperative MI.

    2. POISE2008

      Metoprolol reduced MI but doubled stroke risk (HR 2.17; 95% CI 1.26-3.74) and increased all-cause mortality (HR 1.33; 95% CI 1.03-1.74) due to hypotension and bradycardia.

    3. Reversal2014

      Guidelines updated

    4. Current recommendation

      2014 ACC/AHA Guidelines: Routine acute initiation of beta-blockers on the day of surgery in beta-blocker-naive patients is strictly not recommended.

  2. CardiologyModerate

    Supplemental oxygen in normoxemic acute MI

    Why flagged

    Oxygen ordered in MI patient with O2 sat 91% (normoxemic); DETO2X-AMI 2017 showed no mortality benefit and potential harm in normoxemic patients.

    1. Prior guidance2017

      Universal administration of high-flow supplemental oxygen to all patients with suspected acute myocardial infarction, regardless of baseline saturation.

    2. DETO2X-AMI2017

      No reduction in 1-year all-cause mortality (5.0% vs. 5.1%, HR 0.97, p=NS) or rehospitalization with routine oxygen in normoxemic MI patients.

    3. Reversal2017

      Guidelines updated

    4. Current recommendation

      ESC/ACC/AHA Guidelines (2017): Supplemental oxygen is indicated only if the patient presents with frank hypoxemia (arterial oxygen saturation < 90%).