Perioperative beta-blocker use beneficial in select cardiovascular subgroups

Image: PD 

1. Beta-blocker use was associated with no significant improvement in major cardiovascular adverse events (MACE) or all-cause mortality in all patients with ischemic heart disease undergoing non-cardiac surgery. 

2.  In a sub group of patients with a history of heart failure, there was significant decrease in MACE and all-cause mortality associated with beta-blocker use. 

Evidence Rating Level:  2 (Good) 

Study Rundown: Beta-blocker use for the reduction of cardiovascular risk in patients undergoing non-cardiac surgery has been a controversial topic.  Current European Society of Cardiology guidelines and American guidelines recommend beta-blockers perioperatively for patients undergoing non-cardiac surgery.  However, these guidelines have been called into question as the evidence from the DECREASE family of trials have been delegitimized due to accusations of scientific misconduct centered on the principal investigator of these studies, Don Poldermans, who was the chairman of the committee that drafted these guidelines.

This study found that in patients undergoing non-cardiac surgery, beta-blocker use was associated with a significant decrease in MACE and all-cause mortality only in patients with heart failure (HF).  In those with recent myocardial infarction (<2 years), there was significant decrease in MACE only.  One of the major limitations of the study is the fact that the knowledge of beta-blocker use was based on outpatient prescription records.  Therefore, it is unclear if the beta-blockers were continued in the hospital.  Also, dosages of beta-blockers were not known.  The dosages and their association with adverse events would have been helpful to know, especially since dosing was one of the major criticisms of the POISE trial.

Click to read the study published today in JAMA Internal Medicine 

Relevant Reading: Meta-analysis of secure randomised controlled trials of β-blockade to prevent perioperative death in non-cardiac surgery

In-Depth [retrospective cohort study]: This study is a nationwide cohort study based in Denmark examining all non-cardiac surgical procedures performed in Denmark over a six-year period. Beta-blocker use was determined based on outpatient prescription record. After screening 387,796 non-cardiac surgical procedures, 28,263 patients were identified as having ischemic heart disease.  7,990 of these patients had a history of HF. The primary outcome studied was 30-day risk of MACE, which included acute MI, ischemic stroke, or cardiovascular death. The secondary end point was all-cause mortality occurring within 30 days of surgery.

Overall, beta-blocker use was associated with unadjusted hazard ratio (HR) of 1.03 (95%CI, 0.92-1.14) for MACE and 0.94 (0.85-1.03) for all-cause mortality.  Among patients with HF, MACE was significantly lower (0.78; 95% CI, 0.66-0.91), as well as all-cause mortality (0.82; 95% CI, 0.71-0.95).  Also, in patients with recent MI (<2 years), HR for MACE in the beta blocker group was 0.54 (0.37-0.78) and the HR for all-cause mortality was 0.80 (0.53-1.21).

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