Perioperative β-Blocker Therapy

Abstract

We have previously identified 13 interventions that might change perioperative mortality in adult surgery, among them are perioperative β-blockers (BB). The increased prevalence of cardiovascular (CV) disease together with the awareness of the survival benefit of BB in various cardiac pathologies, promoted a dramatic increase in its utilization. A decrease in the myocardial oxygen consumption to avoid supply/demand mismatch in addition to their anti-arrhythmic properties and known coronary plaque stabilizing effect are the main benefits. Nevertheless, in instances of hypotension during anesthesia or blood loss, failure to sufficiently augment the cardiac output (while on BB) is concerning. The use of perioperative BB to improve cardiac outcomes and mortality before noncardiac surgery continues to be debated, and over the past two decades, several randomized controlled studies showed conflicting results. Due to guideline and institutional recommendations, physicians in charge of the surgical patient have become more liberal with administering BB and are ready to accept the accompanying intraoperative hypotension and bradycardia in favor of possibly improving the cardiac outcome. In 2008, the largest multicenter randomized trial “POISE” demonstrated a significant reduction in CV death but at the cost of an increased mortality and an additional risk of stroke in the BB-treated patients and has raised more questions than answers. Because the evidence from the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) family of trials for the value of perioperative BB is no longer secure, further trials and meta-analyses were performed to investigate its benefit.