Questions Continue About Beta Blockers

<"">Beta blockers have been the subject of some controversy concerning their effects around surgery and, now, a new study questions beta blocker use to reduce surgical risks.  The study found that the death rate for patients taking beta blockers prior to non-cardiac surgery was 10 times higher in the 30 days after an operation than for those not receiving the drugs (2.52% vs. 0.25%), according to a report in the October issue of the Archives of Surgery.  Also, the incidence of heart attacks was found to be four times higher (2.94% vs. 0.74%).

“This is very much in line with the latest publications showing that one has to be very careful in using them,” said study co-author Dr. Kamal Itani, chief of surgery at the Veterans Affairs Boston Health Care System and a professor of surgery at Boston University.  Beta blockers have traditionally been prescribed before surgery to reduce cardiac risk by slowing the heartbeat.  This new study revealed that the risk of problems was higher in people whose heart rates remained high despite beta-blocker treatment.

The major, international POISE study, conducted earlier this year, looked at 8,351 people having non-cardiac surgery and found a 27% reduction in heart attacks but an overall 33% higher death rate for those who received beta blockers.  The Boston results differ somewhat from those of the POISE study.  Despite this, beta blockers do have a role in surgery, Itani said. “I think we have to be careful about which patients receive beta blockers,” he noted, adding, “There are clearly benefits for those drugs in patients at the highest risk of complications and with risk factors for heart disease.”

Itani stressed that it is important to ensure that patients’ target heartbeat rates are achieved.  The American College of Cardiology recommends patients achieve 50 beats to 60 beats per minute prior to surgery, without exceeding 80 beats per minute, said Itani.  “Those patients who do not have the target rate going into surgery will not do as well,” Itani said. “Giving the drugs without achieving the full potential might be dangerous.”  Dr. Jeffrey H. Peters, chief of surgery at the University of Rochester, New York, says that the new study results show that the College of Cardiology guidelines “need to be revisited,” adding, “This paper adds to a growing body of evidence suggesting that the routine use of beta blockers to reduce cardiac morbidity in surgery needs to be reconsidered.”

Meanwhile, the POISE study differed in that it was specifically designed with controls built in while the new Boston study was retrospective, comparing 238 people given beta blockers before surgery with 480 who underwent surgery at the same center without being given the drugs, Peters noted.  “This is a retrospective study that is far from definitive, but it suggests that we should reconsider,” he said.  “We recommend beta blockers for high risk patients, but we currently use them less and less,” Peters said.

Another paper published in the October 28 issue of the Journal of the American College of Cardiology discussed research conducted by cardiologists at Columbia University College of Physicians and Surgeons.  That group found that analysis of data from nine controlled trials revealed a higher incidence of deaths, heart attacks, strokes, and heart failure in patients whose heart rate was lowered with beta-blocker treatment.

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