Patterns of β-blocker initiation in patients undergoing intermediate to high-risk noncardiac surgery

Background Based on 2 small randomized controlled trials (RCTs) from the 1990s, beta-blockers were promoted to prevent perioperative cardiac events in patients undergoing noncardiac surgery. In 2008, a large RCT (POISE trial) showed an increased mortality risk associated with perioperative beta-blockade, raising concerns about an extensive beta-Blocker use. Objectives The objective of the study is to examine patterns of beta-Blocker initiation among patients undergoing noncardiac elective surgery in the US. Methods From a large, nationwide US health care insurer, we identified patients >= 18 years old who underwent moderate-to high-risk noncardiac elective surgery between 2003 and 2012 and initiated a beta-Blocker within 30 days before surgery. We evaluated temporal trends and assessed the impact of the POISE trial on perioperative beta-Blocker initiation. We also evaluated patient characteristics and examined the effect of temporal proximity to surgery on the likelihood of beta-Blocker initiation. Results Of 499,752 patients undergoing surgery, 9,014 (18 per 1,000 patients) initiated a beta-Blocker. beta-Blocker initiation increased from 12 per 1,000 patients in 2003 to 23 before POISE, after which it decreased to 14 by December 2012 (P = .0001). beta-Blocker initiation remained relatively high among patients undergoing vascular surgery or with Revised Cardiac Risk Index score >= 2. Proximity to surgery was highly predictive of beta-Blocker initiation (odds ratio 3.34, 95% CI 3.17-3.51). Conclusions After a period of a rapidly increasing trend, perioperative beta-Blocker initiation decreased sharply in the second half of 2008 and continued to decrease afterwards. beta-Blocker initiation remained relatively high in patients with Revised Cardiac Risk Index score >= 2 and in those undergoing major vascular surgery.