Beta Blockers in NonHeart Surgery QuestionedNov 12, 2008 | Parker Waichman LLP
Scientists report that beta blocker use for noncoronary surgery could actually increase a patient’s risk of stroke. The news was based on an analysis of 33 studies—a meta-analysis—on beta blockers and which concluded the drugs are not useful in any surgical procedure other than heart surgery. Beta blockers inhibit adrenaline; slow nerve impulses to the heart; and can be used to treat irregular heartbeat, known as arrhythmia.
The study’s researchers recommend that the guidelines committees of both the American College of Cardiology and the American Heart Association "soften" their recommendations that beta blockers be used to prevent surgical complications in non-coronary operations. "Our study says that if you look at the overall picture, do a meta-analysis, studies that are not particularly well-done come to the conclusion that they are useful," said Dr. Franz Messerli, professor of medicine at Columbia University and an author of a report published online by The Lancet. The report coincides with the yearly heart meeting currently taking place. "But if you look at the high-quality studies, there are distinctly more strokes with beta blockers."
The meta-analysis revealed a 35 percent reduced risk of heart attacks and a 64 percent reduction in less serious heart artery blockages among the over 12,000 study participants. In all the studies reviewed, beta blockers were prescribed prior to surgery. The meta-analysis found that there was no overall reduction in total deaths, heart failure, or deaths due to heart diseases, but the risk of nonfatal stroke doubled.
Beta blocker use was also associated with a high risk of bradycardia, or low heart rate requiring medical treatment. Bradycardia occurred in one of every 22 patients taking beta blockers, as well as of lower blood pressure that was dangerous enough to mandate treatment. In September 2008, researchers writing in the Journal of the American College of Cardiology also found that beta blockers do not prevent heart failure in patients with high blood pressure and should not be used as first-line treatment for hypertension. The increased stroke risk—occurring in one of every 293 beta blocker recipients—is of particular importance, notes Messerli. "Stroke is one of the most devastating complications of cardiovascular disease," he said. "For that reason, we would be very reluctant to use beta blockers in noncomplicated patients." There is a pre-surgical role for beta blockers in many cases, Messerli said. "If a patient has coronary artery disease, he or she should certainly be on beta blockers," he said. "If they are on beta blockers already, they should remain on beta blockers. But if there is no particular cardiovascular risk, beta blockers should not be prescribed for noncardiac procedures."
Messerli suggests that current recommendations calling for routine pre-surgery use of beta blockers be revised, "This is regarded as a quality measure for physicians," he said. "If they don't prescribe a beta blocker, it is considered to be falling short of a quality measure. Since the data are relatively soft, it certainly should not be a quality measure."