Preoperative β-blocker use correlates with worse outcomes in patients undergoing aortic valve replacement

Commentary: Preoperative β-blockers—One size does not fit all when considering management

“…It is also noted that in both groups of Shubert and colleagues, 4 approximately 27% had moderate to severe aortic insufficiency. Although consideration of the pathophysiology of aortic insufficiency and the dependence on an adequate heart rate to optimize hemodynamics and prevent diastolic distention would suggest that b-blocker therapy would be detrimental, there is 1 study 8 that showed that it had a benefit as long as the heart rate was 70 beats/min or faster.…”

“…That study, however, did not permit heart rate to be less than 70 in these patients. 8 Because more than onequarter of their study group had significant aortic insufficiency, Shubert and colleagues 4 should have verified that the preoperative heart rates were adequate to prevent these patients from entering the operation with compromised ventricles.…”

Treatment of postoperative atrial fibrillation: The long road ahead

“…A meta-analysis of isolated CABG studies found that preoperative beta-blocker use was associated with a significant increase in the incidence of POAF (OR, 1.08; 94% CI, 1.06-1.10; P<.001), 22 whereas a statewide database using propensity matched STS data of patients undergoing aortic valve replacement found preoperative beta-blocker associated with significantly increased POAF, as well as other morbidities of cardiac arrest, renal failure requiring dialysis, and postoperative transfusion. 23 Amiodarone is a Class IIA recommendation for prophylaxis, but there was even greater concern about the riskbenefit ratio in the SCA/EACTA survey. The 2013 Cochrane review of 33 studies similarly found significant heterogeneity (I 2 ¼ 63) and that half of studies began administration postoperatively.…”

Commentary: All members of β-blocker house on probation!

“…These higher risk patients on b-blockers who were excluded from the propensity-matched elective AVR cohort may have further shifted the argument in favor of the position of Schubert and coauthors. 2 The intensive care unit stay was longer in the b-blocker group. Nevertheless, the hospital costs for the b-blocker and non-b-blocker groups were similar ($32,253 vs $32,746).…”

“…How many patients were administered b-blockers solely as a potential quality metric marker is not provided in the article of Schubert and coauthors. 2 Similarly, evidence for discontinuing bblockers for all patients scheduled for elective AVR is not available and will be challenging to obtain.…”