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Revisiting Perioperative Beta-Blockade: Harmful in Low-Risk Patients | Journal Scan
Study Questions:
What is the effect of perioperative beta-blockade on patients undergoing noncardiac surgery (NCS), particularly those with no risk factors?
Methods:
This was a retrospective observational cohort study of patients admitted to 119 Veterans Health Administration (VHA) hospitals. Eligible patients underwent NCS within 24 hours of admission between 2008 and 2013. Beta-blocker use was determined using the start date of the order. If the start date was between 8 hours before admission to the acute care ward and 24 hours after admission, use was indicated. A cardiac risk score (modeled after the Revised Cardiac Risk Index) was determined by assigning one point for each of the following four conditions: creatinine >2.0 mg/dl, coronary artery disease, diabetes, and surgery in a major body cavity. The endpoint was 30-day surgical mortality.
Results:
The analytic sample was comprised of 326,489 patients (314,114 underwent NCS and 12,375 underwent cardiac surgery). Although beta-blockade lowered the odds ratio (OR) for mortality significantly in patients with 3-4 cardiac risk factors undergoing NCS (OR, 0.63; 95% confidence interval [CI], 0.43-0.93), it had no effect on patients with 1-2 risk factors and actually increased risk of death (OR, 1.19; 95% CI, 1.06-1.35) in those with no risk factors. In patients undergoing cardiac surgery, the ORs revealed no consistent pattern of effect of beta-blocker use on mortality with the number of cardiac risk factors.
Conclusions:
Among VHA patients undergoing noncardiac surgery, perioperative beta-blockade is beneficial for patients with 3-4 cardiac risk factors, but not in those with 1-2 risk factors, and harmful in those with no risk factors.
Perspective:
The limitations of this retrospective analysis aside, the authors contribute to the literature on perioperative beta-blockade. Perhaps the most notable finding is the detection of harm associated with perioperative beta-blockade in those with no risk factors. From this analysis, and as the authors acknowledge as a limitation, it is unclear whether the patient was first given the beta-blocker in the hospital or if it was a home medication. Certainly, current guidelines discourage the initiation of perioperative beta-blockade in the hours preceding surgery in patients who are naïve to such therapy. In the circumstances where perioperative beta-blockade is to be initiated in the perioperative period, it should be done so days and weeks in advance of the planned surgery or procedure. Ultimately, the authors present a useful analysis, but several questions and controversies about perioperative beta-blockade remain.
Keywords: Adrenergic beta-Antagonists, Cardiac Surgical Procedures, Cohort Studies, Coronary Artery Disease, Coronary Disease, Creatinine, Diabetes Mellitus, Mortality, Perioperative Period, Retrospective Studies, Risk, Risk Factors, Veterans Health, Secondary Prevention
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