Beta-Blockers is benefit high risk patients around time of noncardiac, nonvascular surgery

FDA Highlights by Bruce Sylvester – Patients with an elevated cardiac risk treated with beta-blockers on the day of or day following non-cardiac, non-vascular surgery have achieved significantly lower rates of 30-day mortality and cardiac illness, researchers reported in the April 24, 2013 issue of JAMA.

They noted as background that the effectiveness and safety of perioperative beta-blockade among for patients undergoing noncardiac surgery is controversial. And Class I recommendations in the current American Heart Association/American College of Cardiology Foundation Guidelines on Perioperative Evaluation and Care for Noncardiac Surgery are not limited to continuation of preexisting beta-blockade.

Martin J. London. M.D., of the U.S. Department of Veterans Affairs Medical Center and University of California, San Francisco, and colleagues conducted a retrospective study of the association of perioperative beta-blockade with all-cause 30-day mortality and cardiac morbidity (cardiac arrest or Q-wave myocardial infarction) in patients undergoing major noncardiac surgery.

The investigators evaluated data on 136,745 subjects (matched 1:1 on propensity scores, in 37,805 matched pairs) who were treated at 104 Veterans Administration (USA) centers from January 2005 through August 2010.

Overall, 45,347 patients (33.2 percent) had an active outpatient prescription for beta-blockers within 7 days of surgery and 55,138 patients (40.3 percent) were potentially exposed to beta-blockers on either postoperative day 0 or 1. Inpatient beta-blocker exposure was higher in the 66.7 percent of 13,863 patients who underwent vascular surgery than in the 37.4 percent of 122,882 patients who underwent nonvascular surgery. The rate of use increased with increasing Revised Cardiac Risk Index variables: 25.3 percent for no factors vs. 71.3 percent for 4 or more factors.

The investigators reported that 1,568 patients (1.1 percent) sustained the primary 30-day mortality outcome and 1,196 patients (0.9 percent) sustained the secondary cardiac morbidity outcome. Subjects in the beta-blocker exposed group had a 27 percent lower risk of mortality.

They found significant associations between beta-blocker exposure and lower mortality in subjects with two Revised Cardiac Risk Index factors (37 percent lower mortality risk), three factors (46 percent lower risk), or four factors or more (60 percent lower risk). This association was limited to patients undergoing nonvascular surgery.

As for the secondary cardiac morbidity outcome, beta-blocker exposure associated with a 33 percent lower risk of cardiac complications. The finding was limited to patients undergoing nonvascular surgery.

The authors added, “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 non-cardiac surgery.”