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Click here: Beta Blockers Raise Stroke, Death Risk After Surgery
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Beta Blockers Raise Stroke, Death Risk After Surgery

By Steven Reinberg, HealthDay Reporter

TUESDAY, May 13 (HealthDay News) -- Patients who received the blood
pressure-lowering drugs known as beta blockers after having non-
cardiac surgery were at higher risk of dying or having a stroke, a new
Canadian study found.

However, the patients receiving the medications were less likely to
have a heart attack, according to the report in the May 13 online
issue of The Lancet.

"For a decade now there are guidelines saying you should give beta
blockers to people having non-cardiac surgery," said lead researcher
Dr. P.J. Devereaux, an assistant professor in the Department of
Clinical Epidemiology and Biostatistics at McMaster University in
Hamilton, Ontario.

The reason for giving beta blockers is that surgery increases the
heart's need for oxygen and beta blockers help reduce blood pressure
and heart rate, reducing strain on the heart, Devereaux explained.

Around the world, an estimated 100 million people have major non-
cardiac surgery each year, so the finding could have serious
consequences for many patients, Devereaux noted.

"In the last decade, even if only 10 percent of patients undergoing
non-cardiac surgery were given beta blockers, that means 100 million
people were given beta blockers, and that means 800,000 people died
unnecessarily and a lot of people suffered a major stroke because they
were given a beta blocker," Devereaux said.

In the study, 8,351 patients at 190 hospitals across 23 countries who
were at risk for atherosclerotic disease [hardening of the arteries]
and undergoing non-cardiac surgery were randomly selected to receive a
beta blocker or a placebo. The beta blocker was given two to four
hours before surgery, and continued for 30 days after the procedure.

The researchers found that patients receiving beta blockers were 16
percent less likely to have died from heart disease, compared with
those receiving a placebo. In addition, those taking a beta blocker
were 27 percent less likely to have a heart attack than patients
receiving a placebo.

But, more people taking a beta blocker died than those taking a
placebo. In fact, patients taking a beta blocker had a 33 percent
increased risk of dying compared with patients taking a placebo.

Also, there were more strokes among people taking a beta blocker than
among patients receiving a placebo. Those receiving the beta blocker
had double the risk of suffering a stroke compared with patients
receiving a placebo, the researchers reported.

The most likely explanation for the increase in deaths and stroke
among those taking beta blockers was that these patients could go into
shock if their blood pressure were too low, a not uncommon
complication of surgery, Devereaux said. "If they were on the beta
blockers they were in big trouble, and [it] increased their likelihood
of dying or suffering a stroke," he said.

Devereaux doesn't think reducing the risk of heart attack is worth
increasing the risk of stroke or death. "I don't think most patients
would be willing to accept the excess death and excess stroke for
preventing a heart attack," he said.

Using a beta blocker to prevent heart attacks in these patients is not
the right strategy, Devereaux said. "If we are causing so much harm to
prevent heart attacks, we need to find another solution which will
prevent these events, but not have the same risk."

One expert thinks that the doses of beta blockers given in the trial
were too high.

"The increase in hypotension [low blood pressure] and resulting
strokes and cardiovascular deaths may be a result of this overly
aggressive dosing rather than perioperative beta blocker therapy in
general," said Dr. Gregg C. Fonarow, a professor of cardiology at the
University of California, Los Angeles.

"While further studies of other beta blockers and dosing regimens for
perioperative use are still needed, the rapid up-titration to high
dose of a beta blocker regimen employed in this study should be
avoided," Fonarow said.

Another expert thinks that if beta blockers are given cautiously, the
dangers found in the study can be greatly reduced.

"We don't want people to misinterpret this study," said Dr. Lee A.
Fleisher, chair of the Department of Anesthesiology and Critical Care
at the University of Pennsylvania School of Medicine, and author of an
accompanying editorial in the journal. "The study did not say anybody
who is on beta blockers should stop them."

Fleisher agrees that starting beta blockers the morning of surgery
with high doses is not a good way to go. "That type of protocol is not
good," he said.

More information

For more on beta blockers, visit the American Academy of Family
Physicians.

SOURCES: P. J. Devereaux, M.D., assistant professor, Department of
Clinical Epidemiology and Biostatistics, McMaster University,
Hamilton, Ontario; Lee A. Fleisher, M.D., chair, Department of
Anesthesiology and Critical Care, University of Pennsylvania School of
Medicine, Philadelphia; Gregg C. Fonarow, M.D., professor, cardiology,
University of California, Los Angeles; May 13, 2008, The Lancet,
online

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