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Are Heart Surgery Risks Lower With Preoperative Beta Blocker Plus Statin?
The combination of statins and beta blockers before cardiac surgery was associated with a lower risk of certain complications afterward, an observational study showed.
According to Medpage Today, patients treated with both statins and beta blockers as part of a policy to maintain pre-existing medication regimens in the 24 hours before cardiac surgery had lower risks, adjusted for baseline differences, than those who got neither for several endpoints:
- Prolonged hospitalization (odds ratio [OR], 0.59; P = 0.01)
- Prolonged mechanical ventilation (OR, 0.61; P = 0.02)
- Reoperations for bleeding (OR, 0.43; P = 0.02)
Beta blockers alone or statins alone had no impact on outcomes, and no comparison turned up any mortality differences, Peyman Benharash, MD, of the University of California at Los Angeles and colleagues reported in a research letter appearing online in JAMA Surgery. Their retrospective review of a single center's Society of Thoracic Surgeons data included 1,930 adults getting cardiac surgery from 2008 through 2014. Among them, 22% got beta blockers alone, 14% got statins alone, 40% got both, and 24% got neither.
MedPage Today reviewer F. Perry Wilson, MD, of Yale, wasn't impressed.
"First, it's an observational cohort from a single center, so I'd be worried that unmeasured confounders dictating who got statins and who got beta blockers drive many of these results," he noted. "POISE was a randomized trial, so the quality of that evidence is much higher."
The researchers acknowledged the controversial state of preoperative beta blocker use, as "several large-scale studies have failed to reproduce these beneficial effects [of earlier studies in reducing major adverse cardiovascular events], and the Perioperative Ischemic Evaluation trial [POISE] found increased mortality with the use of beta blockers before surgery."
Some small trials have suggested lower risk in cardiac surgery with statins, but preoperative dosing is controversial and not part of guideline recommendations, Benharash's group added.
"I also find it odd that there was a significant synergistic effect when beta blockers were used with statins, but essentially no effect when either was used on its own," Wilson told MedPage Today by email. "In addition, the outcomes that were significantly improved by the combination (like bleeding risk) don't suggest a compelling rationale for why both drugs are needed, where one has no effect."
Mechanistically, combining the two could have an advantage because both drug classes may reduce oxidative stress, and beta blockers may additionally reduce the adrenergic surge associated with cardiac surgery, the researchers suggested, calling for prospective randomized studies in larger cohorts.
"All in all, I think the chance that these results are due to chance is pretty significant," Wilson concluded. "Still, this study does provide justification for further looks (in larger, multicenter datasets) for important synergistic effects between these two common medication classes."
Source: Medpage Today, November 19, 2015.