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What’s 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 What’s New in the Patient Safety World column “Beta Blocker Debate Just Won’t 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 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.

 

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 Won’t 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

https://journals.lww.com/anesthesia-analgesia/Fulltext/2021/11000/Beta_Blocker_Therapy_Is_Associated_With_Increased.21.aspx

 

 

 

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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