The American Journal of Medicine
Volume 122, Issue 3 , Pages 222-229 , March 2009

Perioperative Beta-blockers for Major Noncardiac Surgery: Primum Non Nocere

  • Vineet Chopra, MD

      Affiliations

    • Division of General Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor
    • Corresponding Author InformationRequests for reprints should be addressed to Vineet Chopra, MD, University of Michigan Health System, 3119 Taubman Center, 1500 E, Medical Ctr Dr., SPC 5376, Ann Arbor, MI 48109
    • ,
  • Benjamin Plaisance, MD

      Affiliations

    • Division of General Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor
    • ,
  • Erdal Cavusoglu, MD

      Affiliations

    • Division of Cardiology, Department of Medicine, State University of New York Downstate Medical Center, Brooklyn
    • ,
  • Scott A. Flanders, MD

      Affiliations

    • Division of General Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor
    • ,
  • Kim A. Eagle, MD

      Affiliations

    • Division of Cardiovascular Medicine, Department of Medicine, University of Michigan Health System, Ann Arbor

References 

  1. Viljoen JF, Estafanous FG, Kellner GA. Propranolol and cardiac surgery. J Thorac Cardiovasc Surg. 1972;64:826–830
  2. Prys-Roberts C, Foex P, Biro GP, Roberts JG. Studies of anesthesia in relation to hypertension v. adrenergic beta receptor blockade. Br J Anesth. 1973;45:67–81
  3. Remme WJ, Torp-Pederson C, Cleland JG, et al. Carvedilol protects better against vascular events than metoprolol in heart failure: results from COMET. J Am Coll Cardiol. 1997;49:963–971
  4. Thadani U. Selection of optimal therapy for chronic stable angina. Curr Treat Options Cardiovasc Med. 2006;8:23–35
  5. Chen ZM, Pan HC, Chen YP, et al. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomized placebo controlled trial. Lancet. 2005;366:1622–1632
  6. Poldermans D, Boersoma E. Beta-blocker therapy in noncardiac surgery. N Engl J Med. 2005;353:412–414
  7. Eagle KA, Berger PB, Calkins H, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2002;105:1257–1267
  8. Blaustein AS. Preoperative and perioperative management of cardiac patients undergoing noncardiac surgery. Cardiol Clin. 1995;13:149–161
  9. Devereaux PJ, Yang H, Yusuf S, et al. POISE Study Group Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomized controlled trial. Lancet. 2008;371:1839–1847
  10. Yang H, Raymer K, Butler R, et al. The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J. 2006;152:983–990
  11. Juul AB, Wetterslev J, Gluud C DIPOM Trial Group. Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomized placebo controlled blinded multi-centre trial. BMJ. 2006;332:1482
  12. Roth-Isigkeit A, Brechman J, Dibbelt L, et al. Persistent endocrine stress response in patients undergoing cardiac surgery. J Endocrinol Invest. 1998;21:12–19
  13. Devereaux PJ, Goldman L, Young B, et al. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. Can Med Assoc J. 2005;173:627–634
  14. Dawood MM, Gupta DK, Southern J, et al. Pathology of fatal perioperative myocardial infarction: implications regarding pathophysiology and prevention. Int J Cardiol. 1996;57:37–44
  15. Mangano DT. Perioperative cardiac morbidity. Anesthesiology. 1990;72:153–184
  16. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043–1049
  17. Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med. 1995;333:1750–1756
  18. Wallace A, Layug B, Tateo I, et al. Prophylactic atenolol reduces postoperative myocardial ischemia. Anesthesiology. 1998;88:7–17
  19. Yeager MP, Fillinger MP, Hettleman BD, Hartman GS. Perioperative beta-blockade and late cardiac outcomes: a complementary hypothesis. J Cardiothorac Vasc Anesth. 2005;19:237–241
  20. Jenkins NP, Keevil BG, Hutchinson IV, Brooks NH. Beta-blockers are associated with lower C-reactive protein concentrations in patients with coronary artery disease. Am J Med. 2002;112:269–274
  21. Fredriksson HM, Lindquist JM, Bronnikov GE, Nedergaard J. Norepinephrine induces vascular endothelial growth factor gene expression in brown adipocytes through a beta-adrenoceptor/cAMP/protein kinase A pathway involving Src but independently of Erk1/2. J Biol Chem. 2000;275:13802–13811
  22. Anzai T, Yoshikawa T, Takahashi T, et al. Early use of beta blockers is associated with attenuation of serum C-reactive protein elevation and favorable short-term prognosis after acute myocardial infarction. Cardiology. 2003;99:47–53
  23. Stone JG, Foex P, Sear JW, et al. Myocardial ischemia in untreated hypertensive patients: effect of a single small oral dose of a beta-adrenergic blocking agent. Anesthesiology. 1988;68:495–500
  24. Mangano DT, Layug EL, Wallace A, Tateo L. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery (Multicenter Study of Perioperative Ischemia Research Group). N Engl J Med. 1996;335:1713–1720
  25. Devereaux PJ, Yusuf S, Yang H, et al. Are the recommendations to use perioperative beta blocker therapy in patients undergoing non-cardiac surgery based on reliable evidence?. Can Med Assoc J. 2004;171:245–247
  26. Poldermans D, Boersma E, Baxx JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group). N Engl J Med. 1999;341:1789–1794
  27. Auerbach AD, Goldman L. Beta blockers and reduction of cardiac events in noncardiac surgery: scientific review. JAMA. 2002;20:1445–1447
  28. Brady AR, Gibbs JS, Greenhalgh RM, et al. Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: result of a randomized double-blind controlled trial. J Vasc Surg. 2005;41:602–609
  29. Lindenauer PK, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349–361
  30. Devereaux PJ, Beattie WS, Choi PT, et al. How strong is the evidence for the use of perioperative beta blockers in noncardiac surgery? (Systematic review and meta-analyses of randomized controlled trials). BMJ. 2005;331:313–321
  31. Redelmeier D, Scales D, Kopp A. Beta blockers for elective surgery in elderly patients: population based, retrospective cohort study. BMJ. 2005;331:932
  32. Poldermans D, Hoeks S, Feringa HHH. Pre-operative risk assessment and risk reduction before surgery. J Am Coll Cardiol. 2008;51:1913–1924
  33. Feringa HHH, Bax JJ, Boersma E, et al. High-dose beta-blockers and tight heart rate control reduce myocardial ischemia an troponin T release in vascular surgery patients. Circulation. 2006;114:I-344-339
  34. Kaafarani HM, Atluri PV, Thornby J, Itani KM. Beta blockade in noncardiac surgery: outcome at all levels of cardiac risk. Arch Surg. 2008;143:940–944
  35. Beattie WS, Wijesundera DN, Karkouti K, et al. Does tight heart-rate control improve beta blocker efficacy? (An updated analysis of the noncardiac surgical randomized trials). Anesth Analg. 2008;106:1039–1048
  36. National Quality Forum. Safe Practices for Better Healthcare—2006 Update. Washington, DC: National Quality Forum; 2006;
  37. Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess (Summ). 2001;43:i-x, 1-668
  38. Allison JJ, Weissman NW, Silvey AB, et al. Identifying top-performing hospitals by algorithm: Results from a demonstration project. Jt Comm J Qual Patient Saf. 2008;34:309–317
  39. Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med. 2008;149:29–32
  40. Gabel A, Jones R American College of Surgeons/Physician Consortium for Performance Improvement/National Committee for Quality Assurance. Perioperative Care—Physician Performance Measure Set October 2006. http://www.ama-assn.org/ama/pub/category/17762.htm
  41. Zaugg M, Tagliente T, Lucchinetti E, et al. Beneficial effects from beta-adrenergic blockade in elderly patients undergoing non-cardiac surgery. Anesthesiology. 1999;91:1674–1686
  42. Markowitz SM, Gordon MA, et al. Postoperative prophylactic administration of beta-blockers in patients at risk for myocardial ischemia. Anesth Analg. 2000;90:1257–1261
  43. Boersma E, Poldermanns D, Bax JJ, et al. Predictors of cardiac events after major vascular surgery: role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. JAMA. 2001;285:1865–1873
  44. Raby KE, Brull SJ, Timimi F, et al. The effect of heart rate control on myocardial ischemia among high-risk patients after vascular surgery. Anesth Analg. 1999;88:477–482

 Funding: None; no funding received.

 Conflicts of Interest: There are no conflicts of interest for any of the authors.

 Authorship: All authors had access to the data and a role in writing the manuscript.

PII: S0002-9343(08)01121-2

doi: 10.1016/j.amjmed.2008.11.004

The American Journal of Medicine
Volume 122, Issue 3 , Pages 222-229 , March 2009

Article Tools

* Image Usage & Resolution