Early Resumption of β Blockers Is Associated with Decreased Atrial Fibrillation after Noncardiothoracic and Nonvascular Surgery

Abstract

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Beta (β) blockers reduce the risk of postoperative atrial fibrillation and should be restarted after surgery, but it remains unclear when best to resume β blockers postoperatively. The authors thus evaluated the relationship between timing of resumption of β blockers and atrial fibrillation in patients recovering from noncardiothoracic and nonvascular surgery. Methods The authors evaluated 8,201 adult β-blocker users with no previous history of atrial fibrillation who stayed at least two nights after noncardiothoracic and nonvascular surgery as a retrospective observational cohort. After propensity score matching on baseline and intraoperative variables, 1,924 patients who did resume β blockers by the end of postoperative day 1 were compared with 973 patients who had not resumed by that time on postoperative atrial fibrillation using logistic regression. A secondary matched analysis compared 3,198 patients who resumed β blockers on the day of surgery with 3,198 who resumed thereafter. Results Of propensity score–matched patients who resumed β blockers by end of postoperative day 1, 4.9% (94 of 1,924) developed atrial fibrillation, compared with 7.0% (68 of 973) of those who resumed thereafter (adjusted odds ratio, 0.69; 95% CI, 0.50–0.95; P = 0.026). Patients who resumed β blockers on day of surgery had an atrial fibrillation incidence of 4.9% versus 5.8% for those who started thereafter (odds ratio, 0.84; 95% CI, 0.67–1.04; P = 0.104). Conclusions Resuming β blockers in chronic users by the end of the first postoperative day may be associated with lower odds of in-hospital atrial fibrillation. However, there seems to be little advantage to restarting on the day of surgery itself.

Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association

“…Therefore, contemporary evidence indicates that β-blockers should not be started de novo to prevent perioperative myocardial infarction. Nevertheless, patients taking a β-blocker long term should continue therapy or restart after surgery when hemodynamically stable, 57 with the caveat that dose titration might be needed to mitigate risks of postoperative hypotension. There are no randomized trials of β-blockers for preventing MINS, but the pooled effect across relevant observational studies does not suggest clinical benefit.…”

Myocardial injury in noncardiac surgery

“…In the POISE trial, beta-blockers were associated with a decrease in postoperative myocardial infarctions but an increase in the incidence of stroke [ 58 ]. Thus, the use of beta-blockers immediately after surgery should be limited to those patients who already have routine prescriptions [ 59 ]. The use of other cardiovascular drugs, including aspirin, nitrous oxide, and clonidine, in the preoperative period was also investigated as a preventative for MINS, but the results were not significant [ 28 ].…”

Timing of β-Blocker Reintroduction and the Occurrence of Postoperative Atrial Fibrillation after Cardiac Surgery

“…5 Similar statistical associations between transient postoperative atrial fibrillation and morbidity/mortality have been found in noncardiac surgery. 3 Interestingly, transient postoperative atrial fibrillation is also associated with long-term mortality, 6 despite the fact that fewer than 2% of the patients with transient postoperative atrial fibrillation included in a trial were discharged from the hospital with persistent atrial fibrillation. 7 The relationship between postoperative reintroduction of β-blockers after cardiac surgery and the risk of postoperative atrial fibrillation was investigated in several studies.…”

“…For patients under chronic β-blocker therapy, reintroduction of β-blockers as soon as possible after cardiac 1 and noncardiac 2 surgeries is a grade 1 recommendation and is followed by many institutions and clinicians. 3 Early reintroduction of β-blockers is supposed to attenuate the deleterious effects of excessive sympathetic nervous system activation after surgery. 4…”