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Wallace AW, Au S, Cason BA
Anesthesiology. 2011;114:824-836
In this retrospective study, 3787 patients who underwent perioperative beta-blockade were divided into 2 groups: one that received atenolol and one that received metoprolol. The authors performed logistic regression analysis to investigate mortality among patients continuously managed with either one of these agents.
The results indicated that 30-day mortality (1% in the atenolol group vs 3% in the metoprolol group; P < .001) and 1-year mortality (7% vs 13%, respectively; P < .001) differed between the 2 beta-blockers. Propensity matching that corrected for cardiac risk factors found an odds ratio of 2.1 (95% confidence interval, 1.5-2.9; P < .001) for an increase in 1-year mortality with the use of metoprolol. The investigators concluded that perioperative beta-blockade using atenolol is associated with reductions in both short- and long-term postoperative mortality compared with metoprolol.
Wallace and colleagues' study provides evidence suggesting a difference in effectiveness among beta-blockers. Indeed, not all beta-blockers may be equal. A decrease in sudden death after myocardial infarction has been demonstrated only for the more lipophilic beta-blockers, whereasmetoprolol and propranolol have been shown to prevent ventricular fibrillation in clinical trials.[3] Atenolol has a long duration of action and difference in metabolism compared with metoprolol, and this suggests that a long-acting beta-blocker may be superior to a short-acting one.[4,5] More prospective randomized trials are necessary to validate these observational findings sourse.medscape
Anesthesiology. 2011;114:824-836
Summary
Studies have suggested that perioperative beta-blockade reduced postoperative adverse cardiac events in both the short and long term, and current guidelines recommend prophylactic beta-blockade for high-risk patients undergoing noncardiac surgery.[1,2] However, it is still unclear whether the protective effect differs among beta-blockers.In this retrospective study, 3787 patients who underwent perioperative beta-blockade were divided into 2 groups: one that received atenolol and one that received metoprolol. The authors performed logistic regression analysis to investigate mortality among patients continuously managed with either one of these agents.
The results indicated that 30-day mortality (1% in the atenolol group vs 3% in the metoprolol group; P < .001) and 1-year mortality (7% vs 13%, respectively; P < .001) differed between the 2 beta-blockers. Propensity matching that corrected for cardiac risk factors found an odds ratio of 2.1 (95% confidence interval, 1.5-2.9; P < .001) for an increase in 1-year mortality with the use of metoprolol. The investigators concluded that perioperative beta-blockade using atenolol is associated with reductions in both short- and long-term postoperative mortality compared with metoprolol.
Viewpoint
In 2009, on the basis of evidence from many studies, the American College of Cardiology/American Heart Association updated their guidelines, stating that perioperative beta-blockade is a class IIa recommendation for patients with cardiac risk and should be considered during surgery.[1] However, few studies have compared different beta-blockers or characterized their dose effect in the perioperative setting.Wallace and colleagues' study provides evidence suggesting a difference in effectiveness among beta-blockers. Indeed, not all beta-blockers may be equal. A decrease in sudden death after myocardial infarction has been demonstrated only for the more lipophilic beta-blockers, whereasmetoprolol and propranolol have been shown to prevent ventricular fibrillation in clinical trials.[3] Atenolol has a long duration of action and difference in metabolism compared with metoprolol, and this suggests that a long-acting beta-blocker may be superior to a short-acting one.[4,5] More prospective randomized trials are necessary to validate these observational findings sourse.medscape
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