May 8, 2013
Perioperative Use of Beta Blockers Decreased
Cardiac Illness, Mortality

San FranciscoRates of 30-day mortality and cardiac illness dropped significantly when patients at elevated cardiac risk were treated with beta-blockers on the day of or the day following noncardiac, nonvascular surgery, according to a new study.

Authors of the study, which was published in the Journal of the American Medical Association, noted that use of perioperative beta blockers appears to be declining and remains controversial.

“In conclusion, our results suggest that early perioperative beta-blocker exposure is associated with significantly lower rates of 30-day mortality and cardiac morbidity in patients at elevated baseline cardiac risk undergoing nonvascular surgery. Although assessment of cumulative number of Revised Cardiac Risk Index predictors might be helpful to clinicians in deciding whether to use perioperative beta-blockade, the current findings highlight a need for a randomized multi-center trial of perioperative beta-blockade in low- to intermediate-risk patients scheduled for noncardiac surgery,” according to the researchers, led by Martin J. London, MD, of the U.S. Department of Veterans Affairs Medical Center and University of California, both in San Francisco.

For the study, researchers used a population-based sample of 136,745 patients treated at 104 VA medical centers from January 2005 through August 2010 to assess the association of perioperative beta-blockade with all-cause 30-day mortality and cardiac morbidity in patients undergoing major noncardiac surgery.

About a third of the patients, 45,347, had an active outpatient prescription for beta-blockers within 7 days of surgery and another 40.3%, 55,138, were potentially exposed to beta-blockers on either postoperative Day 0 or 1, according to the study. The authors noted that inpatient beta-blocker exposure was higher in the 66.7% of 13,863 patients who had vascular surgery than in the 37.4% of 122,882 patients who had other types of surgery; those with more cardiac risk index factors also were more likely to be administered beta blockers.

The primary 30-day mortality outcome occurred in 1,568 patients (1.1%), with another 1,196 patients (0.9%) having the secondary cardiac morbidity outcome.

Researchers found that patients receiving beta-blockers had a 27% percent lower risk of mortality. Significant associations of beta-blocker exposure with lower mortality were noted in patients with:

• At least two Revised Cardiac Risk Index factors—37% lower;
• Three risk factors—46% lower;
• Four risk factors or more—60% lower.

In terms of the secondary cardiac mobility outcome, beta-blockers were associated with a 33% lower risk of cardiac complications in patients undergoing nonvascular surgery.

“The effectiveness and safety of perioperative beta-blockade [the process of inhibiting beta-receptor activity] for patients undergoing noncardiac surgery remains controversial,” the authors write, nothing that Class I recommendations in the current American Heart Association/American College of Cardiology Foundation Guidelines on Perioperative Evaluation and Care for Noncardiac Surgery remain limited to continuation of use of preexisting beta-blockers.

In fact, they note, “Recent evidence suggests that use of perioperative beta-blockade may be declining. Contributing factors may include uncertainty about safety, and recent data questioning the efficacy of long-term beta-blockade in stable outpatients.”

The article calls for additional multicenter analyses of associations of perioperative beta-blockade with outcomes.

U.S. Pharmacist Social Connect