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. 2019 Aug;123(2):118-125.
doi: 10.1016/j.bja.2019.03.042. Epub 2019 May 14.

Preoperative chronic beta-blocker prescription in elderly patients as a risk factor for postoperative mortality stratified by preoperative blood pressure: a cohort study

Sudhir Venkatesan  1 , Mads Emil Jørgensen  2 , Helen J Manning  3 , Charlotte Andersson  4 , Abdul M Mozid  5 , Mark Coburn  6 , S Ramani Moonesinghe  7 , Pierre Foex  8 , Monty Mythen  7 , Michael P W Grocott  9 , Jonathan G Hardman  10 , Puja R Myles  1 , Robert D Sanders  11
Affiliations

Preoperative chronic beta-blocker prescription in elderly patients as a risk factor for postoperative mortality stratified by preoperative blood pressure: a cohort study

Sudhir Venkatesan et al. Br J Anaesth. 2019 Aug.

Abstract

Background: Recent data suggest that beta blockers are associated with increased perioperative risk in hypertensive patients. We investigated whether beta blockers were associated with an increased risk in elderly patients with raised preoperative arterial blood pressure.

Methods: We conducted a propensity-score-matched cohort study of primary care data from the UK Clinical Practice Research Datalink (2004-13), including 84 633 patients aged 65 yr or over. Conditional logistic regression models, including factors that were significantly associated with the outcome, were constructed for 30-day mortality after elective noncardiac surgery. The effects of beta blockers (primary outcome), renin-angiotensin system (RAS) inhibitors, calcium-channel blockers, thiazides, loop diuretics, and statins were investigated at systolic and diastolic arterial pressure thresholds.

Results: Beta blockers were associated with increased odds of postoperative 30-day mortality in patients with systolic hypertension (defined as systolic BP >140 mm Hg; adjusted odds ratio [aOR]: 1.92; 95% confidence interval [CI]: 1.05-3.51). After excluding patients for whom prior data suggest benefit from perioperative beta blockade (patients with prior myocardial infarction or heart failure), rather than adjusting for them, the point estimate shifted slightly (aOR: 2.06; 95% CI: 1.09-3.89). Compared with no use, statins (aOR: 0.35; 95% CI: 0.17-0.75) and thiazides (aOR: 0.28; 95% CI: 0.10-0.78) were associated with lower mortality in patients with systolic hypertension.

Conclusions: These data suggest that the safety of perioperative beta blockers may be influenced by preoperative blood pressure thresholds. A randomised controlled trial of beta-blocker withdrawal, in select populations, is required to identify a causal relationship.

Keywords: beta blocker; blood pressure; hypertension; mortality; perioperative outcome; risk factors; surgery.

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Conflict of interest statement

The authors declare that they have no conflicts of interest.

Figures

Fig. 1
Fig. 1
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) diagram. GP, general practitioner.
Fig. 2
Fig. 2
Forest plots for the impact of preoperative cardiovascular medications on postoperative mortality for different preoperative systolic BP thresholds. Top row shows unadjusted data, and bottom row shows the results after adjusting for confounders. Columns refer to different BP thresholds. ACE, angiotensin-converting enzyme; CI, confidence interval; OR, odds ratio.
Fig. 3
Fig. 3
Forest plots for the impact of preoperative cardiovascular medications on postoperative mortality for different preoperative diastolic BP thresholds. Top row shows unadjusted data, and bottom row shows the results after adjusting for confounders. Columns refer to different BP thresholds. ACE, angiotensin-converting enzyme; CI, confidence interval; OR, odds ratio.
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