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BetaBlockadeRiskyforNoncardiacSurgeryinLowRiskPatients
LaurieBarclay,MD May29,2015
Perioperativeblockadewasassociatedwithlower30daymortalityinpatientswiththreetofourcardiacriskfactors
undergoingnoncardiacsurgery(NCS),butwithincreasedmortalityinpatientswithnocardiacriskfactors,according
toaretrospectivecohortstudypublishedonlineMay27inJAMASurgery.

"Perioperativeblockadeiswidelyacceptedinpatientswhoundergocardiacsurgery,"writeMarkL.Friedell,MD,
fromtheUniversityofMissouriKansasCitySchoolofMedicine,andcolleagues."However,itsuseinpatients
undergoing[NCS]iscontroversial."

"Ourhypothesiswasthatblockadeisbeneficialinpatientsathighcardiacriskbutmaybeharmfulinthosewith
littleornorisk,"theycontinue.

Inpatientsatlowriskforcardiacevents,useofblockadebeforeorduringNCScarriesincreasedriskforstrokeand
hypotension.Thegoalofthisretrospectiveobservationalanalysiswastoexaminetheeffectofperioperative
blockadeonpatientsundergoingNCS,particularlyamongthosewithnocardiovascularriskfactors.

Thestudycohortconsistedof326,489patientsundergoingNCSsurgery(n=314,114)orcardiacsurgery(n=
12,375)fromOctober1,2008,throughSeptember31,2013,atVeteransAffairshospitals.

Theinvestigatorscalculateda4pointcardiacriskscorebyassigning1pointeachforrenalfailure,coronaryartery
disease,diabetesmellitus,andsurgeryinamajorbodycavity.Amongpatientswiththreeorfourcardiacriskfactors
whohadNCS,blockadeatanytimebetween8hoursbeforesurgeryand24hourspostoperativelysignificantly
loweredtheoddsratioforunadjusted30daysurgicalmortality(oddsratio,0.6395%confidenceinterval,0.43
0.93).

However,blockadehadnoeffectonpatientswithoneortwocardiacriskfactors,anditwasassociatedwith
significantlyincreasedmortalityinpatientswithnoriskfactors(oddsratio,1.1995%confidenceinterval,1.06
1.35).

Unadjusted30daymortalityratesforNCSamongpatientsnotreceivingblockerswere0.5%forpatientswithno
cardiacriskfactors,1.4%forthosewithoneortworiskfactors,and6.7%forthosewiththreeorfourriskfactors.
Amongpatientstreatedwithblockers,theserateswere1.0%,1.7%,and3.5%,respectively.

"blockadeisbeneficialperioperativelyforpatientswith3to4cardiacriskfactorsundergoingNCSbutnotin
patientswith1to2cardiacriskfactors,"thestudyauthorswrite."Mostimportant,theuseofblockersinpatients
withnocardiacriskfactorsappearstobeassociatedwithahigherriskofdeath,whichhas,toourknowledge,not
beenpreviouslyreported."

Limitationsofthisstudyincluderetrospectivedesign,useofaVeteransAffairspopulationconsistingpredominantlyof
men,andlackofdataregardinguseofspecificdrugs,thecausesofdeath,andthenumberofstrokes.Inaddition,it
isunclearwhetherthepatientwasfirstgiventheblockerinthehospitalorathome,whetheritwasgiven
preoperativelyorpostoperatively,andwhetheritwasgivenfortreatmentofacomplication.

Theauthorshavedisclosednorelevantfinancialrelationships.

JAMASurg.PublishedonlineMay27,2015.Fulltext

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