It is estimated that 4–6% of patients with cardiac disease or cardiac risk factors who undergo non-cardiac surgery (NCS) experience an MI, 0.5–1.0% have a stroke, and 2–3% die of cardiovascular or other causes. An exaggerated sympathetic response after NCS has been linked to an increased risk of myocardial ischemia and MI. Perioperative use of a beta-blocker has been shown to reduce myocardial ischemia in NCS patients and has been recommended by the American College of Cardiology and the American Heart Association. Trials including the PeriOperative Ischemic Evaluation (POISE) trial, the largest and most recent, suggest a trade-off between benefits and risks

In this article, the authors critique the key NCS trials and the two most recent meta-analyses. They conclude “perioperative use of b-blockers in NCS can protect against postoperative MI but increases the risk of stroke, severe hypotension, and severe bradycardia. Although less common, the strokes are severe, and the troubling trend toward increasing cardiovascular and total mortality precludes the recommendation for their use in patients not previously treated with beta-blockers.”