The controversy over perioperative use of beta blockers just won’t go away. We’ve addressed the issue in multiple columns (see the list at the end of today’s column). 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. You’ll recall that the POISE trial showed that, though preoperative beta blockers prevented 15 MI’s 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.
But there have been numerous criticisms of the POISE trial. Specifically, patients received fairly large doses of metoprolol shortly before their surgery and many have argued that starting beta blockers well in advance of surgery and titrating the dose slowly would not have produced the adverse outcomes seen in POISE.
There certainly are studies that demonstrate a continued need to continue beta blockers in patients previously taking them. Our November 2010 What’s New in the Patient Safety World column “More Perioperative Beta Blocker Controversy” noted some observational data (Wallace 2010) suggesting that perioperative beta blockade reduces mortality at both 30 days and one year. And that data reinforces that perioperative withdrawal of beta blockers increases mortality. In fact, the Wallace paper showed that beta blocker withdrawal almost quadrupled the 30-day mortality rate and almost doubled the 1-year mortality rate. In our November 2012 What’s New in the Patient Safety World column “Beta Blockers Losing Their Luster?” we noted an observational study supporting the current practice of continuing beta blockers perioperatively in patients who had been taking them prior to their surgery (Kwon 2012). This study, part of a collaborative quality improvement project in Washington state, found that failure to continue beta blockers in patients previously on them almost doubled their rate of adverse events within 90 days after noncardiac surgery.
We previously joked that one pro-beta-blocker article always engenders another anti-beta-blocker article and vice versa! That trend continues.
Now a new observational study again raises the question of utility of perioperative beta blockers in patients undergoing noncardiac surgery (London 2013). The researchers looked at a large population of patients in 104 VA medical centers who underwent major noncardiac surgery and matched them to a control group using propensity scores. They found that among propensity-matched patients undergoing noncardiac, nonvascular surgery, perioperative β-blocker exposure was associated with lower rates of 30-day all-cause mortality in patients with 2 or more Revised Cardiac Risk Index factors.
This study again points out the need for a large randomized controlled trial, similar to the POISE trial that looks at whether the slower, titrated perioperative beta blocker use is of benefit.
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?”
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
Wallace AW, Au S, Cason BA. Association of the Pattern of Use of Perioperative ß-Blockade and Postoperative Mortality. Anesthesiology 2010; 113(4): 794-805
Kwon S, Thompson R, Florencem M, et al. β-Blocker Continuation After Noncardiac SurgeryA Report From the Surgical Care and Outcomes Assessment Program
Arch Surg. 2012; 147(5): 467-473
London MJ, Hur K, Schwartz GG, Henderson WG. Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery. JAMA 2013; 309(16): 1704-1713
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