Association of the pattern of use of perioperative β-blockade and postoperative mortality.
BACKGROUND
The 1996 atenolol study provided evidence that perioperative β-adrenergic receptor blockade (β-blockade) reduced postsurgical mortality. In 1998, the indications for perioperative β-blockade were codified as the Perioperative Cardiac Risk Reduction protocol and implemented at the San Francisco Veterans Administration Medical Center, San Francisco, California. The present study analyzed the association of the pattern of use of perioperative β-blockade with perioperative mortality since introduction of the Perioperative Cardiac Risk Reduction protocol.


METHODS
Epidemiologic analysis of the operations undertaken since 1996 at the San Francisco Veterans Administration Medical Center was performed. The pattern of use of perioperative β-blockade was divided into four groups: None, Addition, Withdrawal, and Continuous. Logistic regression, survival analysis, and propensity analysis were performed.


RESULTS
A total of 38,779 operations were performed between 1996 and 2008. In patients meeting Perioperative Cardiac Risk Reduction indications for perioperative β-blockade, Addition is associated with a reduction in 30-day (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.33 to 0.83; P = 0.006) and 1-yr mortality (OR, 0.64; 95%, CI 0.51 to 0.79; P < 0.0001). Continuous is associated with a reduction in 30-day (OR, 0.68; 95% CI, 0.47 to 0.98; P = 0.04) and 1-yr mortality (OR, 0.82; 95% CI, 0.67 to 1.0; P = 0.05). Withdrawal is associated with an increase in 30-day (OR 3.93, 95% CI, 2.57 to 6.01; P less than 0.0001) and 1-yr mortality (OR, 1.96; 95% CI, 1.49 to 2.58; P < 0.0001).


CONCLUSIONS
Perioperative β-blockade administered according to the Perioperative Cardiac Risk Reduction protocol is associated with a reduction in 30-day and 1-yr mortality. Perioperative withdrawal of β-blockers is associated with increased mortality.
Wallace
Arthur W
AW
Department of Anesthesiology, University of California, San Francisco, California, USA. awallace@cardiacengineering.com
Au
Selwyn
S
Cason
Brian A
BA
D000319:Adrenergic beta-Antagonists / Q000009:adverse effects / Q000627:therapeutic use*; D000368:Aged; D001262:Atenolol / Q000009:adverse effects / Q000627:therapeutic use*; D016208:Databases, Factual; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D007297:Inpatients; D007511:Ischemia / Q000517:prevention & control; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010045:Outpatients; D019990:Perioperative Care; D011183:Postoperative Complications / Q000401:mortality* / Q000517:prevention & control*; D016016:Proportional Hazards Models; D016032:Randomized Controlled Trials as Topic; D040242:Risk Reduction Behavior
D000319:Adrenergic beta-Antagonists; D001262:Atenolol