Case Against Perioperative Beta-Blockers Grows Stronger

PHILADELPHIA — Any beta-blocker use was associated with a higher risk of postoperative stroke, according to research that also found that these medications may factor into racial disparities in stroke risk to some degree.

Based on the records of patients who underwent noncardiac surgeries at two tertiary centers, there was an increased risk of postoperative stroke observed in cases where there had been:

• New beta-blockers initiated within 30 days before surgery (but not recorded anytime prior): adjusted RR 1.25 (95% CI 1.13-1.39)
• Any beta-blocker within 30 days prior to surgery: adjusted RR 1.17 (95% CI 1.10-1.23)
• Sustained beta-blocker use in the year leading up to surgery: adjusted RR 1.08 (95% CI 1.01-1.14)

Compared with the white patients, Black (adjusted RR 1.36, 95% CI 1.29-1.44) and Hispanic peers (adjusted RR 1.09, 95% CI 1.02-1.15) were more likely to receive beta-blockers. They were also more likely to experience a stroke (adjusted RR 1.20, 95% CI 1.12-1.28; and adjusted RR 1.17, 95% CI 1.08-1.27, respectively).

A mediation analysis found that the difference in beta-blocker usage mediated 7.2% of the excess strokes associated with Black race, and 2.0% of the stroke risk for Hispanics, reported Maira Rudolph, MD, of Montefiore Medical Center in New York City, at the American Society of Anesthesiologists (ASA) annual meeting.

This retrospective cohort study extends evidence from the POISE trial, which showed that beta-blockers are associated with an increased risk of stroke and death among surgical patients when first administered 2-4 hours before surgery.

“Any beta-blocker use increased the risk of stroke,” Rudolph said based on the present data, “regardless of when it was given.”

Nevertheless, she cautioned that beta-blockers did show beneficial effects in POISE — namely protection from myocardial infarction and cardiac revascularizations — leading session co-moderator Sabry Ayad, MD, MBA, of Westgate Medical Anesthesia Group in Cleveland, to a question on how clinicians should move forward.

“This is the $1 million question you asked. I don’t think we can answer completely,” said study co-author Matthias Eikermann, MD, PhD, also of Montefiore. He added that his group found that just discontinuing beta-blockers is not good for patients, either, and stressed the need for more research on “how we can use beta-blockers perioperatively.”

The present report included 205,886 adults who underwent noncardiac surgery at Beth Israel Deaconess Medical Center in Boston or Rudolph’s institution from 2005 to 2021. Patients with preoperative atrial fibrillation, people of other races, and those with missing data were excluded from the analysis.

The final cohort self-identified as non-Hispanic white (64.8%), non-Hispanic Black (18.6%), or Hispanic (16.6%).

Rudolph reported that her group did not find evidence that Black and Hispanic patients were simply sicker — and therefore needed more beta-blockers — based on a propensity score matching analysis that adjusted for the many beta-blocker indications and various possible confounders.

There would be other reasons why these groups are getting more beta-blockers — possibly because these medications are relatively cheap and affordable, the researcher suggested.

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