CME: Beta-Blockade & Mortality in Non-Cardiac Surgery

CME: Beta-Blockade & Mortality in Non-Cardiac Surgery

While use of perioperative β-blockers is a widely accepted practice when managing patients undergoing cardiac surgery, using these medications in people who receive non-cardiac surgery is controversial. Years ago, perioperative β-blockade was recommended liberally for patients undergoing non-cardiac surgery after early research demonstrated initial success in patients with cardiac disease. However, this recommendation was based on findings from randomized clinical trials with small samples that may not have included the broad spectrum of patients seen in routine clinical practice. “While some of the initial studies found a benefit by using β-blockade in non-cardiac surgery, other investigations have shown no advantage to this practice,” says Mark L. Friedell, MD. “In fact, some trials have indicated that patients undergoing non-cardiac surgery could be at greater risk for hypotension and stroke if they use β-blockers.” This has created considerable uncertainty about the use of perioperative β-blockers, particularly in patients at low risk of myocardial ischemic events. Examining the Effects Dr. Friedell and colleagues had a study published in JAMA Surgery in which they performed a retrospective observational analysis of patients undergoing surgery in Veterans Affairs (VA) hospitals over a 5-year period. Use of β-blockers was established if a dose was ordered at any time between 8 hours before surgery and 24 hours after the procedure. The authors assessed 30-day mortality outcomes after perioperative β-blockade in patients undergoing non-cardiac surgery with different levels of cardiac risk. For the study, the authors analyzed demographics, diagnosis and procedural codes, medications, perioperative laboratory values, and dates of death. They then used a four-point cardiac risk score that was calculated by assigning one point each for renal...
Beta-Blockade & Mortality in Non-Cardiac Surgery

Beta-Blockade & Mortality in Non-Cardiac Surgery

While use of perioperative β-blockers is a widely accepted practice when managing patients undergoing cardiac surgery, using these medications in people who receive non-cardiac surgery is controversial. Years ago, perioperative β-blockade was recommended liberally for patients undergoing non-cardiac surgery after early research demonstrated initial success in patients with cardiac disease. However, this recommendation was based on findings from randomized clinical trials with small samples that may not have included the broad spectrum of patients seen in routine clinical practice. “While some of the initial studies found a benefit by using β-blockade in non-cardiac surgery, other investigations have shown no advantage to this practice,” says Mark L. Friedell, MD. “In fact, some trials have indicated that patients undergoing non-cardiac surgery could be at greater risk for hypotension and stroke if they use β-blockers.” This has created considerable uncertainty about the use of perioperative β-blockers, particularly in patients at low risk of myocardial ischemic events.   Examining the Effects Dr. Friedell and colleagues had a study published in JAMA Surgery in which they performed a retrospective observational analysis of patients undergoing surgery in Veterans Affairs (VA) hospitals over a 5-year period. Use of β-blockers was established if a dose was ordered at any time between 8 hours before surgery and 24 hours after the procedure. The authors assessed 30-day mortality outcomes after perioperative β-blockade in patients undergoing non-cardiac surgery with different levels of cardiac risk. For the study, the authors analyzed demographics, diagnosis and procedural codes, medications, perioperative laboratory values, and dates of death. They then used a four-point cardiac risk score that was calculated by assigning one point each for...

Beta-Blockade: Minimizing Cardiac Risk During Non-Cardiac Surgery

An estimated 6 million people undergo non-cardiac surgery each year, and up to a quarter of these procedures (eg, major intra-abdominal, thoracic vascular, and orthopedic procedures) are associated with significant risk of perioperative cardiovascular morbidity and mortality. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) issued a practice guideline for the utilization of β-blockade in non-cardiac surgery. The update, published in the November 24, 2009 issue of Circulation and the Journal of the American College of Cardiology, identifies important new information regarding the risks and benefits of perioperative β-blockade. “Non-cardiac surgery represents a stress to the heart, particularly if the procedure is high risk or if patients have underlying risk factors for cardiac complications,” says Kirsten E. Fleischmann, MD, MPH, who chaired the committee that generated the focused update. As the aging population rises and the number of non-cardiac surgeries performed in them continues to increase, steps must be taken to minimize the risk of cardiac complications associated with these surgeries. Clinical Trial Evidence Drives Update Another impetus for the ACCF/AHA update was the publication of new randomized trial data, most notably the POISE (PeriOperative Ischemic Evaluation) and DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography)-IV trials. POISE confirmed that β-blocker therapy reduces perioperative cardiac events, but also clarified that routine perioperative β-blockade—particularly in fixed, higher-dose regimens initiated the day of surgery—was associated with risk. In POISE, the reduction in cardiac events was offset by a higher risk of stroke and death when using fixed higher-doses of metoprolol started on the day of surgery. The DECREASE-IV trial assigned intermediate cardiac risk patients to...