Perioperative β-Blocker Therapy and Survival

Study

Drug

Onset and duration

Surgery

Results

Mangano/1966

200

Atenolol 50–100 mg

Before induction—7-d postop

Noncardiac surgery

Reduced mortality at 6 m (0 vs. 8 %, p < 0.001), at 1 y (3 vs. 14 %, p = 0.005), and at 2 y (10 vs. 21 % p = 0.019)

DECREASE1/1999

112

Bisoprolol 5–10 mg

1-w preop—30 d postop

Major vascular surgery

Decreased cardiac mortality (3.4 vs. 17 %, p = 0.02) and nonfatal MI (0 vs. 17 %, p < 0.001) in the BB group

Lindenauer/2005

122,338

Undetermined

Hospital day 2

Major noncardiac surgery

With RCRI score 0 or 1, there is no benefit and possible harm. With RCRI score 2, 3, and 4 or more, the adjusted OR for inhospital death is 0.88, 0.71, and 0.58, respectively

POBBLE/2005

103

Metoprolol 50 mg BID

1 d before surgery—7-d postop

Infrarenal vascular surgery

No difference in 30-d CV events (32 vs. 34 %) in the BB and placebo group, respectively

MAVS/2006

496

Metoprolol 25–100 mg

2-h preop—5 d or discharge

Vascular surgery

No significant difference in primary outcome^a at 30 d (10.2 vs. 12.0 %) in BB and placebo groups, respectively, (p = 0.57) and at 6 m (p = 0.81)

DIPOM/2006

921

Metoprolol 100 mg ER

1-d preop—8-d postop

Major noncardiac surgery

Primary outcome^b occurred in 21 and 20 % in BB and placebo, respectively (CI 0.80–1.41). All-cause mortality was 16 % in both groups (CI 0.74–1.42 p = 0.88)

BBSA/2007

219

Bisoprolol 5 mg

3-h preop—10 d or discharge

Surgery with spinal block

Primary outcome^c was 22.7 vs. 22.0 % in BB and placebo group, respectively, at 1 y (p = 0.90)

POISE/2008

8,331

Metoprolol ER 200 mg

2–4-h preop—30-d postop

Noncardiac surgery

MI occurred in 4.2 vs. 5.7 % in BB and placebo, respectively, p = 0.017. Mortality was higher in the metoprolol group (3.1 vs. 2.3 %, p = 0.0317). Stroke was more in the metoprolol group (1 vs. 0.5 %, p = 0.0053)

Look to references for expansion of study abbreviations. ER extended release, preop preoperative, postop postoperative, d day, w week, m month, y year, RCRI revised cardiac risk index, MI myocardial infarction, CV cardiovascular, BB β-blocker, OR odds ratio, BID twice a day. ^aPrimary outcome was postoperative 30-day composite incidence of nonfatal myocardial infarction, unstable angina, new congestive heart failure, new atrial or ventricular dysrhythmia requiring treatment, or cardiac death. ^bPrimary outcomes were time to all-cause mortality, acute myocardial infarction, unstable angina, or congestive heart failure. ^cPrimary outcomes were cardiovascular mortality, nonfatal myocardial infarction, unstable angina, congestive heart failure, and cerebrovascular insult

9.2.2 AHA and ESC Guideline Controversies

The conflicting results of these major BB trials and especially the POISE led to several controversies between the ESC [9] and AHA [10] guidelines on perioperative beta blockade. These guidelines were updated after the POISE trial showed increased all-cause mortality and the risk of disabling stroke. Table 9.2 lists the differences in guideline recommendation between the ESC and the AHA. As evident, the AHA adapted a more restrictive approach in contrast to the ESC, which has been more liberal with the administration of perioperative BB. Below is a summary of the main similarities and differences between both societies.

Table 9.2

Summary of recommendations on perioperative β-blockers by the ESC and the AHA

	ESC guideline (August 2009)	ACC/AHA guideline (November 2009)
Class I	BB recommended in patients -with known IHD or myocardial ischemia on preoperative testing (I B) -Undergoing high-risk surgery (I B) -Who were previously treated with BB for IHD, arrhythmias, or hypertension (I C)	BB recommended in patients -Who are receiving BB for treatment of conditions with ACC/AHA Class I indication for the drug (I C)
Class II	BB should be considered in patients -Undergoing intermediate-risk surgery (IIa B) -Previously treated with BB because of chronic heart failure with systolic dysfunction (IIa C) -Scheduled for low-risk surgery with risk factor(s) (IIb B)	BB are probably recommended in patients -Undergoing vascular surgery who suffer from IHD or show ischemia on preoperative testing (IIa B) -In the presence of CAD or high cardiac risk (more than one risk factor) who are undergoing intermediate-risk surgery (IIa B) -Where preoperative assessment for vascular surgery identifies high cardiac risk (more than one risk factor; IIa C) The usefulness of BB is uncertain in patients -Undergoing vascular surgery with no risk factors who are not currently taking BB (IIb B) –Undergoing either intermediate-risk procedures or vascular surgery with a single clinical risk factor in the absence of CAD (IIb C)
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