This article is the first in a three-part series highlighting the complex clinical issues that are facing early career cardiologists. John Ryan, MD, FACC, assistant professor at the University of Utah, interviewed Eiman Jahangir, MD, FACC, consultative cardiologist at Ochsner Medical Center, Hansie Mathelier, MD, FACC, assistant professor at the University of Pennsylvania and Ben Freed MD, FACC, assistant professor at Northwestern University.
In this first of three interviews, Dr. Ryan asks the panel, "In light of the controversies surrounding some of the clinical trials of beta-blockers in modifying peri-operative risk, what is your current approach to the initiation of beta-blockers peri-operatively?"
Eiman Jahangir: With the concerns raised recently over the results of the DECREASE trial, I was waiting to see how the European Society of Cardiology/European Society of Anesthesiology and the American Heart Association/American College of Cardiology would recommend for peri-operative guidelines once reevaluating the data with and without these studies. Even with the removal of the DECREASE trial these agencies found some benefit in the use of beta-blockers peri-operatively.
In my practice, I continue beta-blockers through the peri-operative period in those who have chronically been prescribed these medications. I do not believe there is substantial evidence of increased risk with beta-blockers to justify discontinuing these agents. I also initiate beta-blocker therapy for individuals at high-risk of myocardial ischemia (MI) due to data demonstrating reduction in cardiovascular events, though not surgical mortality, with these agents. Therefore, if I have sufficient concern for ischemia, such as an abnormal stress test, I will initiate beta-blocker therapy prior to surgery.
With low cardiovascular risk individuals or those with no clinical risk factors, the data has demonstrated no benefit and potential harm from beta-blocker initiation. Therefore, I will not start beta-blockers on these low-risk individuals. The gray zone remains those individuals with intermediate cardiovascular risk. Both the European and American guidelines state beta-blockers can be considered in patients with intermediate risk of cardiovascular events, particularly in the setting of a high-risk surgery. Therefore, I evaluate individuals on a case-by-case basis to determine if they may benefit from beta-blockade in the peri-operative setting. Typically, unless the surgery is high risk, I will not initiate beta-blockers in this group and will recommend close heart rate and blood pressure monitoring peri-operatively.
Hansie Mathelier: I started my fellowship in 2009. Luckily, I was assigned to a journal club that was regarding perioperative guidelines and the recent update regarding beta-blockers. In order to prepare for that journal club, I was able to review some of the trials that framed the construction of those guidelines. I still remember the DECREASE trial generating the most discussion during that hour.
Moving forward, my decision to initiate beta-blockers was based on risk factors, type of surgery, and most importantly the timing of the surgery. I would consider initiating a beta-blocker if the patient has hypertension, angina, prior history of myocardial infarction, or if they are in atrial fibrillation or prior history of atrial fibrillation. Ideally, if I was asked to evaluate a patient and they were not on a beta-blocker but had hypertension or prior history of myocardial infarction, I would initiate a beta-blocker at least one week prior to surgery.
After seeing the 2014 guidelines, this is more aligned to how I practiced compared with the 2009 guidelines. If a patient had a three or more Revised Cardiac Risk Index, I would initiate a beta-blocker as long as there was enough time to assess the safety and tolerability before surgery.
Ben Freed: Although nobody questions the use of beta-blockers after MI or for heart failure with reduced ejection fraction, there is still considerable controversy surrounding the question of whether or not beta-blockers should be prescribed for modifying peri-operative risk.
In the 1990s, two small, randomized controlled trials showed a significant reduction in death after randomizing high-risk patients undergoing non-cardiac surgery to either beta-blocker or usual care. Given these results, the POISE-1 Trial randomized over 8000 high-risk patients undergoing non-cardiac surgery to either metoprolol or placebo. While this study also found a reduction in peri-operative MI with beta-blockade, this result was overshadowed by the surprisingly significant increase in bradycardia, hypotension, stroke, and death.
Given the decision by the POISE-1 authors to give large doses (100-200 mg) of long-acting metoprolol to beta-blocker naïve patients (who only needed a SBP > 100 mmHg and a HR > 50 bpm) both immediately before and after surgery, many blamed the trial design for the beta-blocker failure. However, after evidence of serious scientific misconduct came to light for the author who advocated the use of beta-blockers for modifying peri-operative risk, the results of his trials lost all legitimacy.
Although there is reason to believe a lower dose of a short-acting beta-blocker can prevent peri-operative MI without significant risk, there is, as of now, no real evidence. Until further trials are performed showing an absolute benefit of beta-blockers for peri-operative cardiovascular risk reduction, I do not initiate them for this purpose.