Perioperative beta-blockers in noncardiac surgery

Over the past decade, quality measures (QMs) have been implemented nationally in order to establish standards aimed at improving the quality of care. With the expansion of their role in the Affordable Care Act and pay-for-performance, QMs have had an increasingly significant impact on clinical practice. However, adverse patient outcomes have resulted from adherence to some previously promulgated performance measures. Several of these QMs with unintended consequences, including the initiation of perioperative beta-blockers in noncardiac surgery and intensive insulin therapy for critically ill patients, were instituted as QMs years before large randomized trials ultimately refuted their use...

Preoperative cardiac assessment helps identify patients undergoing noncardiac surgery who are at risk for significant postoperative cardiac complications and those who may benefit from additional preoperative evaluation and perioperative care. Advanced practice nurses can identify surgery- and patient-related risks by conducting a thorough health history and physical examination. Multiple risk indices and evidence-based guidelines are available to inform health care providers regarding patient evaluation and strategies to reduce postoperative cardiac risk...

No abstract text is available yet for this article.

Non cardiac surgery is becoming increasingly common in elderly patients; they are usually affected by overt cardiac disease or show multiple risk factors, responsible for a higher incidence of perioperative fatal or nonfatal cardiac events. Of interest, acute myocardial infarction occurring in the perioperative period shows a high mortality rate in people over 65 years old. The cardiovascular risk stratification and perioperative management of subjects undergoing noncardiac surgery have been recently updated in the 2014 European Society of Cardiology Guidelines...

Non cardiac surgery is becoming increasingly common in elderly patients; they are usually affected by overt cardiac disease or show multiple risk factors, responsible for a higher incidence of perioperative fatal or nonfatal cardiac events. Of interest, acute myocardial infarction occurring in the perioperative period shows a high mortality rate in people over 65 years old. The cardiovascular risk stratification and perioperative management of subjects undergoing noncardiac surgery have been recently updated in the 2014 European Society of Cardiology Guidelines...

In August 2014, the American College of Cardiology and American Heart Association updated their guidelines on cardiovascular evaluation and care before noncardiac surgery and simultaneously published a systematic review of perioperative use of beta-blockers. The update reinforces many previous recommendations and provides new evidence and expert opinion that is useful to the perioperative team.

OBJECTIVE: To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates. METHODS: PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery...

The effectiveness and safety of giving beta-blockers to patients undergoing noncardiac surgery remain controversial. The use of these drugs in this clinical scenario increased after the publication of two positive trials in the late 1990s and was encouraged by national organizations and clinical guidelines. However, when several subsequent studies failed to show a benefit, recommendations became more limited and use decreased. This paper reviews recent evidence for and against the perioperative use of beta-blockers...

OBJECTIVE: To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates. METHODS: PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery...

The most common cardiac surgical procedures are coronary artery bypass graft surgery and aortic or mitral valve repair or replacement. Underlying conditions include coronary artery disease and heart failure, manifesting as exertional angina, dyspnea, and poor exercise tolerance. The major goals of surgery are to alleviate symptoms and improve patient survival. These, therefore, should inform the choice of primary outcome measures in clinical studies enrolling patients undergoing cardiac surgery. Studies focusing on surrogate outcome measures are relied on all too often...

BACKGROUND: Although practice guidelines recommend that perioperative β-blockade be initiated at least several days to weeks before noncardiac surgery is performed, the minimum required period of preoperative therapy is unclear. METHODS: Population-based administrative databases were used to conduct a cohort study of 48,103 patients aged ≥ 66 years who underwent major elective noncardiac surgery in Ontario, Canada and received preoperative β-blocker therapy...

BACKGROUND: Perioperative metoprolol increases postoperative stroke. Animal studies indicate that the mechanism may be related to attenuated β(2)-adrenoreceptor-mediated cerebral vasodilatation. The authors therefore conducted a cohort to study whether the highly β(1)-specific β-blocker (bisoprolol) was associated with a reduced risk of postoperative stroke compared with less selective β-blockers (metoprolol or atenolol). METHODS: The authors conducted a single-center study on 44,092 consecutive patients with age 50 yr or more having noncardiac, nonneurologic surgery...

IMPORTANCE: The effectiveness of perioperative β-blockade in patients undergoing noncardiac surgery remains controversial. OBJECTIVE: To determine the associations of early perioperative exposure to β-blockers with 30-day postoperative outcome in patients undergoing noncardiac surgery. DESIGN, SETTING, AND PATIENTS: A retrospective cohort analysis evaluating exposure to β-blockers on the day of or following major noncardiac surgery among a population-based sample of 136,745 patients who were 1:1 matched on propensity scores (37,805 matched pairs) treated at 104 VA medical centers from January 2005 through August 2010...

BACKGROUND: Numerous risk factors have been identified for perioperative stroke, but there are conflicting data regarding the role of β adrenergic receptor blockade in general and metoprolol in particular. METHODS: The authors retrospectively screened 57,218 consecutive patients for radiologic evidence of stroke within 30 days after noncardiac procedures at a tertiary care university hospital. Incidence of perioperative stroke within 30 days of surgery and associated risk factors were assessed...

The effects of differences among β-blockers and initiation times in patients undergoing noncardiac surgery (NCS) remain unknown. On June 1, 2012, the authors searched PubMed, MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to identify all trials of perioperative β-blockers in patients undergoing NCS published between January 1960 and June 2012. The authors included only randomized, double-blind and placebo-controlled trials of perioperatively administered β-blockers (ie, during the pre-, intra- and/or postoperative period) in patients with at least 1 risk factor for coronary artery disease undergoing NCS...

BACKGROUND: It is unclear whether diabetes mellitus or use of particular glucose-lowering agents is associated with increased risk of mortality after noncardiac surgery in patients with known cardiac disease. METHODS: We carried out a retrospective cohort study using 4 linked administrative databases in the province of Alberta, Canada from 1999-2006. RESULTS: Of the 32,834 patients with known cardiac disease in our cohort, 9305 (28%) had diabetes...

Recent allegations of fraud committed by one of the most prolific researchers in perioperative medicine, Don Poldermans, have left many clinicians in a state of disbelief. With over 500 peer-reviewed publications, Poldermans heavily influenced the clinical practice of perioperative beta-blockers and statins in noncardiac surgery, shaping guidelines and national policies on the use of these treatments. The effects of fraud in perioperative medicine are particularly caustic owing to a profound domino effect. Many investigators devoted their academic careers to following the footsteps of investigators such as Poldermans...

Hypertension is an extremely pervasive condition that affects a large percentage of the world population. Although guidelines exist for the treatment of the patient with elevated blood pressure, there remains a paucity of literature and accepted guidelines for the perioperative evaluation and care of the patient with hypertension who undergoes either cardiac or noncardiac surgery. Of particular importance is defining the patients most vulnerable to complications and the indications for immediate and rapid antihypertensive treatment and/or cancellation of surgery to reduce these risks in each of the three perioperative settings: preoperative, intraoperative, and postoperative...

BACKGROUND: Largely on the basis of 2 randomized trials published in the 1990s, β-blockers were initially promoted as an evidence-based intervention for preventing cardiac complications of noncardiac surgery. However, subsequent studies raised concerns about a widespread use of perioperative β-blockade. Little is known regarding how this changing evidence influenced the use of perioperative β-blockers in clinical practice. METHODS AND RESULTS: We conducted a population-based, time-series analysis (April 1999 to March 2010) among residents of Ontario, Canada (age 66 years and older), to evaluate the influence of research publications and practice guidelines on rates of new β-blocker prescriptions before major elective noncardiac surgery...

BACKGROUND: The use of β-blockers during the perioperative period remains controversial. Although some studies have demonstrated their protective effects regarding postoperative cardiac complications, others have demonstrated increased mortality when β-blockers were introduced before surgery. METHODS: In this observational study involving 1,801 patients undergoing aortic reconstruction, we prospectively assessed β-blocker therapy compared with no β-blocker therapy, with regard to cardiac and noncardiac postoperative outcomes using a propensity score approach...