Perioperative beta-blockade, the pros and cons: The story of beta-blockade and cardiac protection

© Springer International Publishing Switzerland 2016. Once considered to confer cardiac protection, perioperative betablockade is now regarded as potentially harmful as reduction of cardiac complications is associated with increased all-cause mortality and increased risk of strokes. Over the past decades relatively small studies were not powered enough to detect relatively rare complications, thus all-cause mortality and increased risk of stroke never reached statistical signifi cance, and were discounted. It needed a large randomised controlled trial (RCT) POISE with more than 8,000 patients for these clinically important complications to reach statistical signifi cance. POISE did not address the issue of acute goal-directed administration of beta-blockers when clinically indicated for the management of cardiovascular instability, such as tachycardia, hypertension, myocardial ischaemia, thus practice needs not change. However, initiating beta-blockade for cardiac protection needs to consider the balance of risk and benefi ts for each individual patient. With considerable caution in respect of beta-blockers, other pharmacological agents need to be considered. While showing promise in previous relatively small studies, clonidine and aspirin have been found in POISE 2, a RCT with over 10,000 patients, to offer no cardiac protection. Clonidine caused hypotension and aspirin increased bleeding. There is limited data and evidence for cardiac protection in respect of calcium channel blockers, ACE inhibitors, angiotensin receptor antagonists and nitroglycerin. However, observational studies and limited RCTs, mostly in cardiac surgery, suggest that statins offer perioperative protection and should be initiated in patients who need them for medical reasons.