Reply: Beta or worse: More work needed to determine benefit or harm in aortic valve surgery

Abstract

can influence specific postreplacement outcomes. Mazzeffi and Evans 1 remind us that these caveats are reasons why preoperative beta-blocker therapy might not be responsible for the increased rates of atrial fibrillation, transfusion, and renal dialysis seen after aortic valve replacement.My impression is that preoperative beta-blocker therapy was a marker for sicker patients undergoing aortic valve replacement. Even in the propensity-matched cohorts, the patients taking a beta-blocker medication had an increased incidence of coronary artery disease, prior coronary artery bypass grafting procedure, renal dialysis, and cerebral vascular accidents.Patients undergoing transcatheter aortic valve replacement during the study period were at moderate to high risk and consequently likely to have been receiving a beta-blocker medication. Those patients were excluded from the propensity-matched aortic valve replacement cohorts and potentially influenced the authors' conclusions.A carefully planned study controlling the duration and selectivity of the preoperative beta-blocker medication will be required before we can conclude that adding beta-blocker therapy to elective aortic valve replacement protocols affects outcomes.

Reply from the authors: Big data and beta blockers: The best of times, the worst of times

“…As all commentators and our limitations section note, the beta-blocker type, dose, and duration were not avilable. [2][3][4][5][6][7] As Mazzeffi and colleagues 4 correctly point out, there is large variability in beta selectivity among the different agents. We can only make assumptions, and a reasonable one would be that prescribing practices mirror the general population, for whom the majority receive nonselective agents.…”