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Whats New in the
Patient Safety World
December 2021
Beta-Blockers
Making a Comeback?
Perioperative use of
beta-blockers engendered lots of controversy for several years. In our May 2013
Whats New in the Patient Safety World column Beta Blocker Debate Just
Wont Go Away we joked that
one pro-beta-blocker article always engenders another anti-beta-blocker article
and vice versa!
Most of you recall
the history of the debate. After several years in which we pushed for almost
universal use of beta-blockers perioperatively, publication of the POISE trial
(Devereaux 2008) significantly changed things. The POISE
trial showed that, though preoperative beta-blockers prevented 15 MIs for every 1000 patients treated, there was an increased
risk of stroke and an excess of 8 deaths per 1000 patients treated. Largely
since that time recommendations have been to continue beta-blockers in the
perioperative period in patients previously taking them but most no longer
begin them perioperatively in patients not previously taking them.
Reserachers in 2020 reported on a
cohort study that used data from the prospectively collected Swedish National
Quality Registry for hip fractures to identify all patients over 40 years of
age subjected to surgery for hip fractures between 2013 and 2017 in one Swedish
county (Mohammad Ismail
2020). The found that beta-blocker therapy was associated with a
significant reduction in 90-day postoperative mortality after hip fracture
surgery.
The researchers expanded on this work with a restrospective cohort study of over 130,000 Swedish
patients who underwent hip fracture surgery from 2008 to 2017 (Mohammad
Ismail 2021). Patients who filled a prescription within the year before and
after surgery were defined as having ongoing beta-blocker therapy. Because this
was not a randomized trial, the researchers adjusted the data using the inverse
probability of treatment weighting (IPTW). Beta-blocker therapy was associated with
a 42% reduction the risk of mortality within the first postoperative year.after adjusting for age, sex,
comorbidities, ASA physical status, fracture, and surgery type.
A previous report on that population by these authors (Ahl 2021)
showed that beta-blocker therapy resulted in a 72% relative risk reduction in
30-day all-cause mortality and was independently associated with a reduction in
deaths of cardiovascular, respiratory, and cerebrovascular origin and deaths
due to sepsis or multiorgan failure. The current report (Mohammad
Ismail 2021) showed that, after excluding patients who died within the
first 30 days postoperatively, beta-blocker therapy was associated with a 27%
reduction in the risk of mortality.
The authors conclude that the evidence presented emphasizes
the importance of maintaining beta-blocker therapy in hip fracture patients but that beta-blocker therapy remains significantly
underused for a large proportion of surgical patients. However, they are quick
to point out that, with the evidence currently available, it is not possible to
recommend initiating beta-blocker therapy in beta-blocker naive patients. They
strongly recommend investigating this possibility using an interventional study
design.
We, of course, agree that the results of this sort of
retrospective observational study should simply be considered as
hypothesis-generating. But the results are suggestive enough that it would seem
a randomized controlled trial in this population would be worthwhile. Seems the
perioperative beta-blocker debate is never-ending!
Our prior columns on
perioperative use of beta blockers:
November 20, 2007 New
Evidence Questions Perioperative Beta Blocker Use
November 4, 2008 Beta
Blockers Take More Hits
December 2009 Updated
Perioperative Beta Blocker Guidelines
November 2010 More Perioperative Beta Blocker Controversy
November 2012 Beta Blockers Losing Their Luster?
May 2013 Beta Blocker Debate Just Wont Go Away
September 2013 More Perioperative Beta-Blocker Controversy
November 2013 Another Assault on Perioperative
Beta-Blockers
References:
Devereaux PJ, Yang H, Yusuf S, et al for the POISE Study
Group. Effects of extended-release metoprolol succinate in patients undergoing
non-cardiac surgery (POISE trial): a randomised
controlled trial. Lancet 2008; 371(9627): 1839-1847
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2808%2960601-7/fulltext
Mohammad Ismail A, Borg T, Sjolin
G, et al. β-adrenergic blockade is associated with a reduced risk of
90-day mortality after surgery for hip fractures. Trauma Surg Acute Care Open
2020; 5: e000533.
https://tsaco.bmj.com/content/5/1/e000533
Mohammad Ismail A, Ahl R, Forssten
MP, et al. Beta-Blocker Therapy Is Associated With
Increased 1-Year Survival After Hip Fracture Surgery: A Retrospective Cohort
Study. Anesthesia & Analgesia 2021; 133(5): 1225-1234
Ahl R, Mohammad Ismail A, Borg T, et al. A nationwide observational
cohort study of the relationship between beta-blockade and survival after hip
fracture surgery. Eur J Trauma Emerg Surg 2021;
Published online January 28, 2021. doi:10.1007/s00068-020-01588-7
https://link.springer.com/article/10.1007/s00068-020-01588-7
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