Perioperative Β-blocker Use Research Articles

Періопераційне застосування β-адреноблокаторів у пацієнтів високого ризику

Незважаючи на краще розуміння того, які бувають передвісники розвитку хронічної серцевої недостатності та які сигнальні системи лежать в основі її патофізіології, а також покращення результатів терапії, значна кількість пацієнтів, особливо похилого віку, не отримують ефективного лікування. Пацієнти похилого віку з такою патологією зазвичай вимагають додаткового об’єму діагностики й значного розширення спектра анестезіологічних заходів у відділеннях інтенсивної терапії. Анестезіологи мають потребу в удосконаленні періопераційного знеболювання при проведенні оперативних втручань. Препарати групи β-адреноблокаторів для лікування пері­операційної гіпертензії, ішемії й аритмій призначаються в передопераційному періоді в групі пацієнтів, які раніше не отримували такого лікування. Періопераційне призначення β-адреноблокаторів у пацієнтів високого ризику використовується недостатньо. Проте питання про те, чи мають β-адреноблокатори знову застосовуватись у передопераційному періоді виключно для запобігання негативним наслідкам хронічної серцевої недостатності, залишається вельми дискутабельним.

Perioperative use of β-blockers in oncological patients

Background. One of the most common responses to surgical stress is the activation of the sympathetic nervous system, leading to a dramatic increase in circulating adrenaline and norepinephrine, which can potentially accelerate the spread of the tumor process in cancer patients. In this regard, it is relevant to review the results of studies devoted to the determination of the antitumor effect of β-blockers and their use in the perioperative treatment of cancer patients.
 Purpose – to analyze and summarize data on the oncogenic effects of catecholamines and to highlight the experience of using β-blockers in the perioperative treatment of cancer patients. Materials and methods. We used the electronic resources of Vernadsky National Library of Ukraine, Cochrane library and databases (Pubmed, Scopus). We analysed the results of studies conducted before August 2020.
 Results. A summary of the mechanisms by which excessive release of catecholamines may facilitate metastasis is provided. The analysis of clinical trials devoted to the study of the effects of perioperative use of propranolol and its combination with COX-2 inhibitors in cancer patients is conducted.
 Conclusions. Short-term perioperative therapy with propranolol and its combination with anti-inflammatory drugs may have antimetastatic effects and neutralize the immunosuppressive effects of surgical stress. Further elucidation of the clinical significance of perioperative propranolol treatment in cancer patients requires a 3–5-year study to assess the long-term relapse-free survival of cancer patients.

Perioperative baseline β-blockers: An independent protective factor for post-carotid endarterectomy hypertension.

Post-carotid endarterectomy hypertension is a well-recognized phenomenon closely related to surgical complications. This study aimed to determine whether different kinds of perioperative antihypertensive drugs had a protective effect on post-carotid endarterectomy hypertension and influence on intraoperative hemodynamics. We retrospectively investigated 102 carotid stenosis patients who underwent conventional endarterectomy with a perioperative baseline antihypertensive regimen. Post-carotid endarterectomy hypertension was defined as a postoperative peak systolic blood pressure ≥160 mmHg and/or a requirement for any additional antihypertensive therapies. We compared the clinical characteristics and types of baseline perioperative antihypertensive drugs between patients with and without post-carotid endarterectomy hypertension and then determined the significant independent effect of antihypertensive drugs on post-carotid endarterectomy hypertension through multivariate regression and detected their influence on intraoperative hypertension (induction-related systolic blood pressure and vasodilators consumption) and hemodynamic depression (intra-arterial systolic blood pressure ≤100 mmHg and/or heart rate ≤50beats/min). We also investigated adverse events such as stroke, death, myocardial infarction, and cerebral hyperperfusion syndrome during the postoperative hospitalization. A total of 52/102 (51.0%) patients were defined as having post-carotid endarterectomy hypertension during the first three days postoperative, including eight patients with a postoperative systolic blood pressure that exceeded 160 mmHg at least once, 31 patients requiring postoperative antihypertensive treatment in addition to their baseline regimen, and 13 patients with both. The incidence of stroke/death/myocardial infarction and cerebral hyperperfusion syndrome after conventional endarterectomy during hospitalization were both 1.9%. A significantly increased risk of composite postoperative complications (including cerebral hyperperfusion syndrome, hyperperfusion-related symptoms, transient ischemic attacks, stroke, death, and cardiac complications) was observed in patients with post-carotid endarterectomy hypertension than without (15.4% versus 2.0%, p = 0.032). Patients free of post-carotid endarterectomy hypertension had a higher incidence of perioperative baseline β-blocker use than patients who suffered from post-carotid endarterectomy hypertension (46.0% versus 21%, p = 0.008). In multivariate analysis, β-blocker use was a significant independent protective factor for post-carotid endarterectomy hypertension (OR = 0.356, 95% CI: 0.146-0.886, p = 0.028). Patients taking β-blockers had a lower postoperative peak systolic blood pressure than the β-blocker-naïve population (137.1 ± 12.1 mmHg versus 145.0 ± 11.2 mmHg, p = 0.008), but the postoperative mean systolic blood pressure showed no intergroup difference. However, the incidence of hemodynamic depression during conventional endarterectomy was higher in patients with perioperative β-blocker use than in those without (44.1% versus 25.0%, p = 0.050). The difference in intraoperative hemodynamic depression became more prominent between the β-blocker and non-β-blocker groups (81.8% versus 33.3%, p = 0.014) for whose preoperative baseline heart rate was equal to or lower than 70beats/min. The perioperative use of β-blockers is a protective factor for post-carotid endarterectomy hypertension and contributes to stabilizing the postoperative peak systolic blood pressure three days after conventional endarterectomy. However, β-blockers might also lead to intraoperative hemodynamic depression, especially for patients with a low baseline heart rate.

Perioperative β-blocker use: what is new in 2020?

Although the indications for β-blockers in the management of patients with congestive heart failure and myocardial infarction are well established, the use of β-blockers in the perioperative setting remains controversial. Since 2008 PeriOperative ISchemic Evaluation Trial, there have been numerous studies suggesting that perioperative β-blockers are associated with adverse events such as hypotension, bradycardia, increased mortality, and stroke. In this article, we review the most recent evidence to suggest an approach to perioperative β-blocker use tailored to patient and surgical risk factors. We also review recent studies on off-label uses for perioperative β-blockers.

Contemporary personalized β-blocker management in the perioperative setting.

Beta-adrenergic blockers (β-blockers) are clearly indicated for the long-term treatment of patients with systolic heart failure and post-acute myocardial infarction. Early small-scale studies reported their potential benefits for perioperative use; subsequent randomized controlled trials, however, failed to reproduce earlier findings. Furthermore, their role in reducing major postoperative cardiac events following noncardiac and cardiac surgery remains controversial. This case-based review presents an overview of contemporary literature on perioperative β-blocker use with a focus on data available since 2008 when the PreOperative ISchemic Evaluation (POISE) trial was published. Our review suggests that studies should determine the effects of situational-based guidelines on perioperative β-blocker use on the risk of cardiac adverse events and mortality in the perioperative period.

The perioperative period: a critical yet neglected time window for reducing the recurrence risk of endometriosis?

While surgery is commonly the management of symptomatic endometriosis when patients do not respond to medical or supportive therapy, recurrence after surgery poses a serious challenge, and repeat surgery increases the risk of premature ovarian failure, adhesion and organ injury. Conceivably, the recurrent endometriotic lesions could arise from minimal residual lesions (MRLs) or from de novo lesions. However, several lines of evidence suggest that the former is more likely. So far, most, if not all, efforts to combat recurrence have been focused on postoperative medication of hormonal drugs to reduce recurrence risk through lesional dormancy and possibly atrophy. However, the perioperative period may exert a disproportionally high impact on the risk of recurrence; it is likely to be amendable for possible intervention but has been generally neglected. Indeed, many perioperative factors are known to or conceivably could facilitate the recurrence of endometriosis through the suppression of cell-mediated immunity due to the activation of adrenergic signaling and the release of prostaglandins. Perioperative use of β-blockers and/or nuclear factor κB/jCycloxygenase 2 (NF-κB/COX-2) inhibitors may boost the cell-mediated immunity suppressed by surgery, resulting in the partial or even complete removal of MRLs and reduced recurrence risk. This is both biologically plausible and supported by a recent experimental study. We call for more research on possible perioperative interventions to reduce the recurrence risk of endometriosis. The potential payoff might be a substantial reduction in the risk of recurrence and cost when compared with the traditional approach of postoperative intervention.

β-blocker Use is Associated with a Reduction in Opioid Use 30 Days After Total Knee Arthroplasty

Background: Total knee arthroplasty (TKA) can lead to chronic pain and prolonged postoperative opioid use. There are few evidence-based interventions to prevent these outcomes. Recently, β-blockers have emerged as possible novel analgesics. Objectives: The objective of this study was to determine whether perioperative β-blocker use is associated with reduced prolonged postoperative opioid use after TKA. Study Design: This study used a retrospective cohort design. Setting: The research took place within Department of Veterans Affairs hospitals in the United States between April 2012 and April 2016. Methods: Patients: IRB approval was obtained to examine the records of Veterans Affairs (VA) patients undergoing TKA. Patients using opioids 60 days before surgery were excluded. Intervention: The intervention being investigated was perioperative β-blocker use, overall and by class. Measurement: Oral morphine equivalent usage through postoperative day 1 and prescription opioid refills through 30, 90, and 365 days after TKA were recorded. Adjusted models were created controlling for relevant demographic and comorbidity covariates. A secondary analysis examined the same outcomes separated by β-blocker class. Results: The cohort was 93.8% male with a mean age of 66 years. Among the 11,614 TKAs that comprised the cohort, 2,604 (22.4%) were performed on patients using β-blockers. After adjustment, β-blocker use was associated with reduced opioid use through 30 days after surgery (odds ratio [OR] 0.89 [95% confidence interval (CI), 0.80-0.99], P = .026). Selective β-blockers were associated with reduced opioid use at 30 days (OR 0.88 [95% CI, 0.78-0.98], P = .021), and nonselective β-blockers were associated with reduced oral morphine equivalent usage through postoperative day 1 (β = -17.9 [95% CI, -29.9 to -5.8], P = .004). Limitations: Generalizability of these findings is uncertain, because this study was performed on a cohort of predominantly white, male VA patients. This study also measured opioid use, but opioid use is not a perfect surrogate for pain. Nevertheless, opioid use offers value as an objective measure of pain persistence in a national cohort for which patient-reported outcomes are otherwise unavailable. Conclusions: Perioperative β-blocker use was associated with reduced prescription opioid use at 30 days after surgery. Both selective and nonselective β-blockers were associated with reduced opioid use when analyzed individually. Key words: Analgesics, opioid, arthroplasty, replacement, knee, adrenergic beta-antagonists, pain management

Perioperative Intervention by β-Blockade and NF-κB Suppression Reduces the Recurrence Risk of Endometriosis in Mice Due to Incomplete Excision

Despite the demonstrated efficacy of surgical treatment of endometriosis, recurrence after surgery still remains a formidable challenge. Surgery, especially when performed repeatedly, decreases ovarian reserve. Clearly, control of recurrence is an unmet medical need. So far nearly all efforts to control recurrence have been devoted to the identification of risk factors, biomarkers, and postoperative medication. One area that has been completely overlooked is the possibility of perioperative intervention. In this study, we tested the hypothesis that perioperative use of a nonspecific β-blocker and/or a nuclear factor-κB (NF-κB) inhibitor can retard the growth of residual endometriotic lesions that are left intact in the primary surgery. We established a mouse model of recurrence due to incomplete lesion removal by deliberately leaving residual lesions intact in the primary excision surgery. One hour before and 24 hours after the surgery, mice were either untreated or treated with andrographolide, propranolol, or both. Two weeks after the primary surgery, all mice were sacrificed and all lesions were excised and evaluated for immunohistochemistry analysis. We found that perioperative use of andrographolide and/or propranolol significantly decelerated the growth of residual lesions that were intentionally left out during the primary surgery. The perioperative intervention also significantly attenuated the generalized hyperalgesia resulting from the presence of residual lesions. It also inhibited the activation of the adrenergic receptor β2 signaling, resulting in reduced angiogenesis, epithelial-mesenchymal transition, fibroblast-to-myofibroblast transdifferentiation as well as NF-κB suppression and progesterone receptor isoform B induction. These data strongly suggest that perioperative use of β-blockers and/or NF-κB inhibitors may reduce the risk of recurrence in endometriosis.

Association between perioperative β-blocker use and clinical outcome of non-cardiac surgery in coronary revascularized patients without severe ventricular dysfunction or heart failure.

Perioperative use of β-blocker has been encouraged in patients undergoing non-cardiac surgery despite weak evidence, especially in patients without left ventricular systolic dysfunction (LVSD) or heart failure (HF). This study evaluated the effects of perioperative β-blocker on clinical outcomes after non-cardiac surgery among coronary revascularized patients without LVSD or HF. Among a total of 503 patients with a history of coronary revascularization (either by percutaneous coronary intervention or coronary arterial bypass grafts) undergoing non-cardiac surgery, those without severe LVSD defined by ejection fraction over 30% or HF were evaluated. The primary outcome was a composite of death, myocardial infarction, repeat revascularization, and stroke during 1-year follow-up. Perioperative β-blocker was used in 271 (53.9%) patients. During 1-year follow-up, we found no significant difference in primary outcome between the two groups on multivariate analysis (hazard ratio [HR], 1.01; confidence interval [CI] 95%, 0.56–1.82; P = 0.963). The same result was shown in propensity-matched population (HR, 1.25; CI 95%, 0.65–2.38; P = 0.504). In coronary revascularized patients without severe LVSD or HF, perioperative β-blocker use may not be associated with postoperative clinical outcome of non-cardiac surgery. Larger registry data is needed to support this finding.

Beta-Adrenergic Receptor Blockers in Hypertension: Alive and Well

Beta-adrenergic receptor blockers (β-blockers) are an appropriate treatment for patients having systemic hypertension (HTN) who have concomitant ischemic heart disease (IHD), heart failure, obstructive cardiomyopathy, aortic dissection or certain cardiac arrhythmias. β-Blockers can be used in combination with other antiHTN drugs to achieve maximal blood pressure control. Labetalol can be used in HTN emergencies and urgencies. β-Blockers may be useful in HTN patients having a hyperkinetic circulation (palpitations, tachycardia, HTN, and anxiety), migraine headache, and essential tremor. β-Blockers are highly heterogeneous with respect to various pharmacologic properties: degree of intrinsic sympathomimetic activity, membrane stabilizing activity, β1 selectivity, α1-adrenergic blocking effects, tissue solubility, routes of systemic elimination, potencies and duration of action, and specific properties may be important in the selection of a drug for clinical use. β-Blocker usage to reduce perioperative myocardial ischemia and cardiovascular (CV) complications may not benefit as many patients as was once hoped, and may actually cause harm in some individuals. Currently the best evidence supports perioperative β-blocker use in two patient groups: patients undergoing vascular surgery with known IHD or multiple risk factors for it, and for those patients already receiving β-blockers for known CV conditions.

Inhibition of β2-adrenergic receptor reduces triple-negative breast cancer brain metastases: The potential benefit of perioperative β-blockade.

In response to recent studies, we investigated an association between perioperative β-blockade and breast cancer metastases. First, a retrospective study examining perioperative β-blocker use and cancer recurrence and metastases was conducted on 1,029 patients who underwent breast cancer surgery at the City of Hope Cancer Center between 2000 and 2010. We followed the clinical study and examined proliferation, migration, and invasion in vitro of primary and brain-metastatic breast cancer cells in response to β2-activation and inhibition. We also investigated in vivo the metastatic potential of propranolol-treated metastatic cells. For stage II breast cancer patients, perioperative β-blockade was associated with decreased cancer recurrence using Cox regression analysis (hazard's ratio =0.51; 95% CI: 0.23–0.97; p=0.041). Triple-negative (TN) brain-metastatic cells were found to have increased β2-adrenergic receptor mRNA and protein expression relative to TN primary cells. In response to β2-adrenergic receptor activation, TN brain-metastatic cells also exhibited increased cell proliferation and migration relative to the control. These effects were abrogated by propranolol. Propranolol decreased β2-adrenergic receptor-activated invasion. In vivo, propranolol treatment of TN brain-metastatic cells decreased establishment of brain metastases. Our results suggest that stress and corresponding β2-activation may promote the establishment of brain metastases of TN breast cancer cells. In addition, our data suggest a benefit to perioperative β-blockade during surgery-induced stress with respect to breast cancer recurrence and metastases.

Effect of Perioperative β-Blockers on Pulmonary Complications among Patients with Chronic Obstructive Pulmonary Disease Undergoing Lung Resection Surgery.

The aim of this study is to determine if COPD patients undergoing lung resection with perioperative β-blocker use are more likely to suffer postoperative COPD exacerbations than those that did not receive perioperative β-blockers. Methods. A historical cohort study of COPD patients, undergoing lung resection surgery at Memorial Sloan-Kettering Cancer Center between 2002 and 2006. Primary outcomes were the rate of postoperative COPD exacerbations, defined as any initiation or increase of glucocorticoids for documented bronchospasm. Results. 520 patients with COPD were identified who underwent lung resection. Of these, 205 (39%) received perioperative β-blockers and 315 (61%) did not. COPD was mild among 361 patients (69% of all patients), moderate in 117 patients (23%), and severe in 42 patients (8%). COPD exacerbations occurred among 11 (5.4%) patients who received perioperative β-blockers and among 20 (6.3%) patients who did not. Secondary outcomes, which included respiratory failure, 30-day mortality, and the presence or absence of any cardiovascular complication, ICU transfer, cardiovascular complication, or readmission within 30 days, did not differ in prevalence between the two groups. Conclusions. This study implies that perioperative β-blockers use among COPD patients undergoing lung resection surgery does not impact the rate of exacerbations.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Study casts doubt over guidelines for perioperative β-blocker use

Study casts doubt over guidelines for perioperative β-blocker use

Perioperative β-blocker use in non-cardiac surgery increases mortality

Perioperative β-blocker use in non-cardiac surgery increases mortality

The role of ivabradine in the incidence of perioperative coronary complications in patients undergoing vascular surgery

The management of perioperative myocardial damage is focused on two issues: coronary plaque stabilization to reduce acute coronary syndromes and the subsequent supply ischemia (type 1MI) that occurs when a coronary plaque ruptures; and limiting surgical stress, which is the cause of the sustained myocardial oxygen supply–demand imbalance (type 2 MI) [1]. Prophylactic pre-operative coronary revascularization in patients scheduled for non-cardiac surgery has failed to show any benefit [2,3]. In contrast, the most recent guidelines recommended the use of β-blockers in patients having high-risk surgery [4]. On the other hand, results of some other clinical trials do not support the use of perioperative β-blockers for the high risk of bradycardia and hypotension, stroke and death [5,6]. Ivabradine, specific inhibitor of the If current in sinoatrial node myocytes, reduces heart rate independently of sympathetic activation, and has demonstrated a reduction in the risk of coronary events in patients with elevated heart rate (≥70 bpm) or angina at baseline [7,8]. The objective of the current study was to determine if ivabradine would be equally effective to β-blockers in reducing cardiovascular risk in patients undergoing major vascular surgery in whom beta-blockers were contraindicate or unsafe. 244 consecutive patients scheduled for open or endovascular aortic aneurysm repair. The internal review board approved the study project and all patients gave their informed consent. Patients with ≤2 cardiac risk factors on the Lee index score and a heart rate b 70 bpm were directly referred for surgery with optimal medical therapy, which must have been initiated at least 30 days before. Patients with ≥3 clinical risk factors on the Lee index score were referred for non-invasive cardiac stress testing echocardiography before surgery as recommended in the ESC guidelines [4]. All patients in the study received optimal medical therapy according to current guidelines [9] for at least 30 days before the planned surgical procedure and all patients with a heart rate ≥ 70 bpmwere assigned to a heart rate control strategy with βblockers or ivabradine. In the β-blocker group, bisoprolol 2.5 mgwas started once a day and titrated to achieve thepreferred restingheart rate range (60–65 bpm). In eligible patients, ivabradine was administered at a dose of 5–7.5 mg twice a day,with the sameheart rate target. The samedose ofβ-blockers or ivabradine was continued post-operative. At the discharge we confirm the treatment for six months and then to consult their cardiologist. The primary endpoint was a composite of all-cause mortality and nonfatal MI that occurred between screening and 30 days after the surgical procedure. Postoperative events were cardiac and overall complications. Troponin T levels were routinely recorded on postoperative days 1 and3orwhenever therewere symptomsor evidenceof new myocardial ischemia.

A Recipe for Perioperative Cardioprotection

The question of what is the ideal anesthetic for patients with cardiovascular disease has been debated for nearly 3 decades, and, similar to the case for the use of perioperative β-blockers, the answer appears to be increasingly enigmatic. In the current issue of Circulation , Buse et al1 report the results of a randomized clinical trial to evaluate the effects of the volatile anesthetic sevoflurane versus the intravenous anesthetic propofol on the incidence of myocardial ischemia in 385 patients with known coronary artery disease or with ≥2 risk factors for coronary artery disease undergoing noncardiac surgery. Using continuous electrocardiography and troponin T plasma concentrations as the composite primary end point of the study, the incidence of myocardial ischemia was similar in both groups (sevoflurane, 40.8%; propofol, 40.3%), calling into question the current American College of Cardiology/American Heart Association guidelines recommending the use of volatile anesthetics for patients at cardiovascular risk who are undergoing noncardiac surgery.2 Article see p 2696 In the mid-1980s, volatile anesthetic agents, particularly isoflurane, were shunned by cardiac anesthesiologists for fear that these agents might induce myocardial ischemia because of coronary steal. High-dose opioids were favored as an alternative technique during anesthesia for cardiac surgery. The myth of isoflurane-induced steal was later debunked both by animal studies3 and clinical trial data.4 By the early 1990s, volatile anesthetic use during cardiac surgery had gained considerable popularity, primarily because it allowed patients to be fast-tracked for early extubation within hours of arrival to the intensive care unit as compared with opioid-based anesthetics. In 1997, the phenomenon of anesthetic preconditioning was first described,5 and subsequently a large body of experimental evidence …

Clinical Evidence, Practice Guidelines, and β-Blocker Utilization Before Major Noncardiac Surgery

Largely on the basis of 2 randomized trials published in the 1990s, β-blockers were initially promoted as an evidence-based intervention for preventing cardiac complications of noncardiac surgery. However, subsequent studies raised concerns about a widespread use of perioperative β-blockade. Little is known regarding how this changing evidence influenced the use of perioperative β-blockers in clinical practice. We conducted a population-based, time-series analysis (April 1999 to March 2010) among residents of Ontario, Canada (age 66 years and older), to evaluate the influence of research publications and practice guidelines on rates of new β-blocker prescriptions before major elective noncardiac surgery. In an analysis of 249 828 procedures, the rate of new β-blocker prescriptions increased from 26.3 per 1000 procedures in April 1999 to 62.7 per 1000 procedures in the first quarter of 2005, after which it decreased to 19.7 per 1000 procedures by March 2010. We observed a marked decrease in prescriptions (P=0.004) during early 2005, without any preceding publications that raised concerns about perioperative β-blockade. There was no change (P=0.98) in prescription rates after the May 2008 publication of a multicenter, randomized trial that showed increased mortality from perioperative β-blockade. Prescribing trends remain unchanged after revisions of related practice guidelines in 2002 (P=0.28) and 2006 (P=0.53). After a period characterized by increasing adoption of preoperative β-blockade between 1999 and 2005, prescriptions rates subsequently fell from 2005 to 2010. Further research is needed to understand the basis for these changes, which are only partially explained by evidence of potential harm.

Cemented Versus Uncemented Hemiarthroplasty for Displaced Femoral Neck Fractures

To prospectively compare the functional outcome associated with cemented and uncemented hemiarthroplasty. Prospective randomized control trial. University-affiliated level 1 trauma center. All individuals designated for hemiarthroplasty, older than 55 years, with a nonpathologic displaced femoral neck fracture and the ability to ambulate 10 feet independently before injury [269 patients (274 hips) presented with displaced femoral neck fracture, 130 patients (48.3%) enrolled, and 5 patients (3.8%) withdrew]. Hip hemiarthroplasty with a cemented femoral prosthesis (VerSys LD/Fx; Zimmer, Warsaw, IN) or an uncemented component (VerSys Beaded FullCoat; Zimmer, Warsaw, IN). Instrumental Activities of Daily Living and Physical Activities of Daily Living scales (Older Americans Resources and Services Instrument) and the Energy/Fatigue Scale. No statistically significant differences were present in the groups' preoperative or intraoperative characteristics, including American Society of Anesthesiologists grade, operative time, anesthesia time, use of perioperative β-blockers, estimated blood loss, or the rate of intraoperative fracture. Postoperatively, no difference was found in hemoglobin level, transfusion rate, discharge disposition, or acute complication rate. At 30-day, 60-day, and 1-year follow-ups, no clinically or statistically significant differences were found in mortality, disposition, need for assistance with ambulation, Older Americans Resources and Services Activities of Daily Living subscales, or the Energy/Fatigue Scale. In the treatment of nonpathologic displaced femoral neck fractures, the use of cemented and uncemented femoral components is associated with similar functional outcome at 1 year. Practitioners may inform their clinical decisions using these equally good results. Therapeutic Level II. See page 128 for a complete description of levels of evidence.

Safety of perioperative β-blocker use: how do β-blockers compare in terms of side effects?

Introduction: In the perioperative setting, there is still a high incidence of adverse cardiac events due to sudden coronary plaque rupture or oxygen supply–demand imbalance. β-Blockers play an important role in preventing these cardiac events. Discussion, however, remains on the side effects accompanying this therapy.Areas covered: The evidence for perioperative use of β-blockers is summarized in this review in terms of risk reduction, perioperative safety and current clinical use. Furthermore, data on pharmacokinetics, pharmacodynamics and pharmacogenetics are presented.Expert opinion: In perioperative care, β-blockers are recommended and can be given safely when started early in a low dose, titrated to heart rate. In the future, there could be a place for added perioperative short-acting β-blockers to further optimize heart rate control.