Propafenone (Rhythmol) (see Propafenone, [[Propafenone]]): with additional Class 1C antiarrhythmic properties (inhibits sodium channels)
Propanolol (Inderal) (see Propanolol, [[Propanolol]])
Sotalol (Betapace, Betapace AF, Sotalex, Sotacor) (see Sotalol, [[Sotalol]]): with additional Class III antiarrhythmic properties (inhibits potassium channels)
Timolol (Blocadren, Timoptic) (see Timolol, [[Timolol]])
Cardioselective (β1-Selective) Beta Blockers
Acebutolol (Sectral, Prent) (see Acebutolol, [[Acebutolol]])
Carvedilol (Coreg) (see Carvedilol, [[Carvedilol]])
Labetalol (Normodyne, Trandate) (see Labetalol, [[Labetalol]])
Pharmacology
β-Adrenergic Receptor Antagonism
Inhibition of Atrioventricular Nodal Conduction
Vasodilation
Clinical Aspects
Retrospective Review of the Impact of Peri-Operative Beta Blocker Use on Inpatient Mortality (2005)MEDLINE]
Study: retrospective review of patients undergoing major non-cardiac surgery (n = 782,969 in 329 US hospitals)
Main Findings
Perioperative beta-blocker therapy was associated with a reduced risk of in-hospital death among high-risk, but not low-risk, patients undergoing major noncardiac surgery
RCRI score 0-1: treatment was associated with no benefit and possible harm
RCRI score 2: adjusted odds ratios for death in the hospital was 0.88 (95 percent confidence interval, 0.80 to 0.98)
RCRI score 3: adjusted odds ratios for death in the hospital was 0.71 (95 percent confidence interval, 0.63 to 0.80)
RCRI score 4 or more: adjusted odds ratios for death in the hospital was 0.58 (95 percent confidence interval, 0.50 to 0.67)
Initiation of extended-release metoprolol succinate increased mortality and strokes in non-cardiac surgery patients
Meta-Analysis of Studies Examining Peri-Operative Beta Blocker Use (Excluding DECREASE Series of Trials) (2014) [MEDLINE]
Study: meta-analysis of randomized controlled trials of β-blockade on perioperative mortality, non-fatal myocardial infarction, stroke and hypotension in non-cardiac surgery
Importantly excluded the discredited DECREASE trials (author of trials and discussant for development of the guidelines was notably dismissed for academic dishonesty)
Main Findings
Initiation of a course of β-blockers before surgery resulted in a 27% risk increase in 30-day all-cause mortality (p=0.04)
β-blockade decreased non-fatal myocardial infarction (RR 0.73, p=0.001), but increased stroke (RR 1.73, p=0.05) and hypotension (RR 1.51, p<0.00001)
The results were dominated by the large POISE trial
Separate analysis of the DECREASE trials contradict the meta-analysis related to mortality (p=0.05 for divergence)
Current guidelines (which are based on the DECREASE trials) need to be revised
May especially occur when used in conjunction with other negative chronotropes which slow heart rate and atrioventricular nodal conduction (such as digoxin or calcium channel blockers)
Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]]): due to negative inotropy
May occur in some cases, especially when used in conjunction with other negative inotropes and chronotropes (such as calcium channel blockers)
Masking of Hypoglycemia-Induced Tachycardia (see Hypoglycemia, [[Hypoglycemia]]): beta blockers may mask tachycardia (but not necessarily the diaphoresis or dizziness) which occur in hypoglycemia
Masking of Hyperthyroidism-Induced Tachycardia (see Hyperthyroidism, [[Hyperthyroidism]])
Abrupt withdrawal of beta blockers in this setting may precipitate thyroid storm
Paradoxical Increase in Blood Pressure in Pheochromocytoma (see Pheochromocytoma, [[Pheochromocytoma]]): when used alone and not in combination with alpha blockers, beta blockers may paradoxically increase blood pressure (due to attenuation of the beta receptor-mediated vasodilatation in skeletal muscle)
Therefore, in pheochromocytoma, beta blockers should only be initiated after alpha blockers have been initiated
Potentiation of the Hypertensive Response that Occurs with Clonidine Withdrawal (in Patients on Concomitant Clonidine and Beta Blockers)
In such cases, it is advised to withdraw the beta blocker at least several days before withdrawing the clonidine
Avoid Abrupt Discontinuation of Beta Blockers: especially in peri-operative period
References
Acebutolol-induced pleuropulmonary lupus syndrome. Ann Intern Med 1981; 95: 326 [MEDLINE]
Atenolol-induced interstitial pneumonia. Ann Intern Med 1997; 148: 505-507 [MEDLINE]
Betaxolol and drug-induced lupus complicated by pericarditis and large pericardial effusion. West J Med 1997; 167: 106-109 [MEDLINE]
Adverse effects of a single dose of (+)-sotalol in patients with mild stable asthma. Br J Clin Pharmacol 1998; 46: 79-82 [MEDLINE]
Bronchiolitis obliterans with organizing pneumonia. Retrospective study of 19 cases. Rev Pneumol Clin 1998; 54: 136-143 [MEDLINE]
Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005 Jul 28;353(4):349-61 [MEDLINE]
Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008 May 31;371(9627):1839-47. doi: 10.1016/S0140-6736(08)60601-7. Epub 2008 May 12 [MEDLINE]
Meta-analysis of secure randomised controlled trials of β-blockade to prevent perioperative death in non-cardiac surgery. Heart. 2014 Mar;100(6):456-64. doi: 10.1136/heartjnl-2013-304262. Epub 2013 Jul 31 [MEDLINE]
