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ventricular contractility or anti-arrhythmic properties of ␤-blockers. ␤-blockers may also prevent plaque rupture in coronary arteries by reducing mechanical stress on the coronary plaques (Lopez-Sendon J, et.al. Eur Heart J 2004:25:1341 and may decrease circulating levels of C-reactive protein thereby stabilizing coronary plaques through anti inflammatory mechanisms (Jenkins NP, et.al. Am J Med 2002;112:269-74). The duration of ␤-blocker treatment before vascular surgery and its effect on cardiovascular outcome in vascular surgical patients has not, however, been specifically studied. The authors sought to evaluate the timing of ␤-blocker initiation and its influence on preoperative heart rate, C-reactive protein levels, and post operative outcome in a cohort of patients undergoing vascular surgery.Preoperative heart rate and high sensitive C-reactive protein (CRP) levels were recorded in 940 vascular surgical patients with respect to time of the ␤-blocker initiation before surgery. Initiation of ␤-blocker's was divided into three time periods, Ͻ1 week prior to surgery, 1-4 weeks prior to surgery, and Ͼ4 weeks prior to surgery. Troponin-T measurements were JOURNAL

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common indication for warfarin therapy was DVT (56.3%). Most patients were considered to be at low risk for VTE recurrence at the time of warfarin interruption (1431 procedures [79.0%]) according to the consensus guidelines of the American College of Chest Physicians. Clinically relevant bleeding within 30 days after the procedure in the bridge therapy and nonbridge therapy groups were recorded in 15 patients (2.7%) and 2 patients (0.2%) respectively, (hazard ratio of 17.2; 95% confidence interval, 3.9-75.1). There was no significant difference in the rate of recurrent VTE between bridge and non-bridge therapy groups (0 vs 3; P ¼ .56). There were no deaths in either group. Comment: The data strongly indicate that in patients treated with warfarin for previous VTE that is unnecessary to provide bridge therapy to undergo an invasive diagnostic or surgical procedure. In fact, such therapy appears to place the patients at increased risk of bleeding. It is, however, important to recognize that the data applies only to patients who were treated with standard warfarin therapy for VTE, not those being treated with newer oral anticoagulation agents or those treated for atrial fibrillation or those being treated with anticoagulation for the presence of a mechanical heart valve. Nevertheless the paper seems to be an important contribution in that it helps to further define and specify who requires bridge therapy for performance of an invasive diagnostic or surgical procedure and who does not.