Bleeding risk modifies perioperative beta-blocker benefits

Perioperative use of beta blockers seems to be beneficial unless patients experience heavy bleeding, in which case it may be detrimental, say researchers.

Some previous studies have suggested that beta-blockers may worsen outcomes in the event of major bleeding, so Yannick Le Manach (Pitié-Salpêtrière Hospital, Paris, France) and colleagues assessed records of 1801 patients who underwent infrarenal aortic reconstruction, which carries a significant bleeding risk.

"We expect that the observed results should be less marked in less hemorrhagic surgeries," they comment in Anesthesiology.

Just over a third (37.5%) of the patients in the team's study received preoperative beta-blocker treatment, but this was closely tied to the presence of cardiac disease and the use of other cardiovascular medications, prompting the researchers to adjust their analysis for patients' propensity to receive beta blockers.

This showed overall benefits among patients who had normal bleeding, defined as needing fewer than five cups (one cup being about 250 mL) of treated or transfused blood. In these patients, beta-blocker use was associated with a 45% reduction in the risk for postoperative myocardial damage (abnormal cardiac troponin I levels). This group represented 59.2% of the overall cohort, making beta-blocker use generally beneficial for a majority of patients.

In patients with increased bleeding (5-10 cups treated/transfused blood; 37.1% of the cohort), the cardioprotective effect of beta blockers was no longer significant and the risk for multi-organ dysfunction syndromes rose 2.46-fold.

Beta-blocker use was clearly linked to poor outcomes in patients with severe bleeding, (>10 cups; 9.1% of the cohort), being associated with a 6.65-fold increase in mortality risk and a 4.18-fold rise in the risk for multi-organ dysfunction syndromes.

The interaction between bleeding severity and the effects of beta blockers resulted in the protective effect on myocardial outcomes in the overall cohort being somewhat offset by the risk for organ dysfunction.

Le Manach et al note that there is currently no way to accurately predict severe perioperative bleeding, but suggest that there may be a better overall risk-benefit balance in surgeries where bleeding is less of an issue, such as orthopedic surgery.

"Other approaches should be considered, including the use of short-acting β-blockers that could be titrated in case of hemorrhagic complications," they add.

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