Should this patient receive perioperative β-adrenergic blockade?
The following describes a randomized, double-masked, placebo-controlled trial to compare the effect of atenolol with that of a placebo on overall survival and cardiovascular morbidity in patients at cardiac risk who were undergoing noncardiac surgery. Atenolol was given intravenously before and immediately after surgery and orally thereafter for the duration of hospitalization. Patients were followed over the subsequent 2 years. Of 200 patients, 99 were assigned to the atenolol group, and 101 to the placebo group. One hundred ninety-four patients survived to be discharged from the hospital, and 192 of these were followed for 2 years. Overall mortality after discharge from the hospital was significantly lower among the atenolol-treated patients than among those who were given placebo, over the 6 months following hospital discharge (0 vs. 8%, P < 0.001), over the first year (3% vs. 14%, P = 0.005), and over 2 years (10% vs. 21%, P = 0.019). The principal effect was a reduction in deaths from cardiac causes during the first 6 to 8 months. Combined cardiovascular outcomes were similarly reduced among the atenolol-treated patients; event-free survival throughout the 2-year study period was 68% in the placebo group and 83% in the atenolol-treated group (P = 0.008). The incidence of diabetes mellitus may have had a confounding influence on this study, but the results suggest that perioperative β-adrenergic blockade is potentially quite beneficial in high-risk patients.