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Perioperative Beta-Blockers Increase Risks After Noncardiac Surgery

Perioperative beta-blockers increase the risk for stroke and death after noncardiac surgery, according to a study published online in Lancet.

In an international, double-blind, industry-supported study, some 8350 patients with (or at risk for) atherosclerotic disease were randomized preoperatively to a 30-day regimen of extended-release metoprolol or placebo. Patients already receiving beta-blockers were excluded.

By 30 days, patients on metoprolol showed favorable results for the primary endpoint (a composite of cardiovascular death, nonfatal MI, and nonfatal cardiac arrest) — but they had significantly higher rates of death and stroke.

The authors write that current perioperative guidelines ought to be reconsidered. Commentators agree that the regimen used carries more risk than benefit; however, they recommend a lower-dose long-acting regimen that is "titrated to effect" at least 7 days before surgery. That regimen, they say, "is associated with overall benefit compared to risk."

Asked to comment, Journal Watch Cardiology editor-in-chief Harlan Krumholz says that using extended-release metoprolol to reduce risk in patients undergoing noncardiac surgery "has suddenly become a lot more controversial than it was yesterday. If this strategy is contemplated, then it should be done with the patient's knowledge of the potential trade-offs in outcomes."

[Editor's note: Although Lancet has released this study from embargo, it has not posted it on its website. Rather than delay coverage while awaiting those postings, we have provided a link to Lancet's early-release page, where the study will eventually appear.]

LINK(S):

Lancet early online publication page (Free)

Published in Physician's First Watch May 13, 2008