This topic was selected because an evidence synthesis beats a textbook on it: the trials disagree, or the guidance has moved recently.
THE EVIDENCE
What each source contributes, and how strong it is
Study design first — a cohort and a randomised trial do not carry the same weight.
Design
Year
Journal
What it found
Meta-analysis
2014
Heart (British Cardiac Society)
Pooling only the trials whose data remain secure, starting a beta-blocker before
Randomised trial
2008
England)
Starting extended-release metoprolol before noncardiac surgery reduced myocardial
Cohort
2005
The New England journal of medicin
The association between perioperative beta-blockade and survival tracks baseline risk
Review
2018
Journal of cardiothoracic and vasc
Ultra-short-acting agents such as esmolol and landiolol offer the effects of
Cohort
2013
JAMA
Beta-blocker exposure around major noncardiac surgery was associated with lower
Review
2026
British journal of anaesthesia
Long-term preoperative beta-blocker prescription is independently associated with
6 resolved citations behind this deck; every point above traces to one of them.
WHERE THE GUIDANCE SITS
Pooling only the trials whose data remain secure, starting a beta-blocker before
Meta-analysis · Heart (British Cardiac Society)
Pooling only the trials whose data remain secure, starting a beta-blocker before noncardiac surgery increased 30-day all-cause mortality by 27%, and increased stroke and hypotension while reducing non-fatal myocardial infarction.
Meta-Analysis of Secure Randomised Controlled Trials of Β-Blockade to Prevent Perioperative Death in Non-Cardiac Surgery, Heart (British Cardiac Society) 2014 · PMID 23904357
WHAT THE TRIALS FOUND
Starting extended-release metoprolol before noncardiac surgery reduced myocardial
Randomised trial · England)
Starting extended-release metoprolol before noncardiac surgery reduced myocardial infarction from 5.7% to 4.2% but increased death from 2.3% to 3.1% and doubled stroke from 0.5% to 1.0%.
Effects of Extended-Release Metoprolol Succinate in Patients Undergoing Non-Cardiac Surgery (POISE Trial): A Randomised Controlled Trial, Lancet (London, England) 2008 · PMID 18479744
THE NUMBERS
POISE: fewer infarcts, more deaths and strokes
Extended-release metoprolol versus placebo, 8,351 patients.
Starting a beta-blocker traded one harm for another — fewer infarcts, but more deaths and double the strokes.
Effects of Extended-Release Metoprolol Succinate in Patients Undergoing Non-Cardiac Surgery (POISE Trial): A Randomised Controlled Trial, Lancet (London, England) 2008 · PMID 18479744
IN PRACTICE
What the cohorts and reviews add
4 findings, each on the slide that follows.
The New England journal of medicine 2005
The association between perioperative beta-blockade and survival tracks baseline risk
The association between perioperative beta-blockade and survival tracks baseline risk: benefit appeared at a Revised Cardiac Risk Index of 2 or more,…
Journal of cardiothoracic and vascular anesthesia 2018
Ultra-short-acting agents such as esmolol and landiolol offer the effects of
Ultra-short-acting agents such as esmolol and landiolol offer the effects of beta-blockade without the detrimental effects of long-acting agents,…
JAMA 2013
Beta-blocker exposure around major noncardiac surgery was associated with lower
Beta-blocker exposure around major noncardiac surgery was associated with lower 30-day mortality only in patients with two or more Revised Cardiac…
British journal of anaesthesia 2026
Long-term preoperative beta-blocker prescription is independently associated with
Long-term preoperative beta-blocker prescription is independently associated with increased postoperative ischaemic stroke risk at 30 and 365 days,…
IN PRACTICE
The association between perioperative beta-blockade and survival tracks baseline risk
Cohort · The New England journal of medicin
The association between perioperative beta-blockade and survival tracks baseline risk: benefit appeared at a Revised Cardiac Risk Index of 2 or more, with no benefit and possible harm at a score of 0 or 1.
Perioperative Beta-Blocker Therapy and Mortality after Major Noncardiac Surgery, The New England journal of medicine 2005 · PMID 16049209
THE NUMBERS
Benefit tracks baseline cardiac risk
Adjusted odds of in-hospital death by Revised Cardiac Risk Index score.
Association with survival appeared only from RCRI 2 upward; at 0–1 there was no benefit and possible harm.
Perioperative Beta-Blocker Therapy and Mortality after Major Noncardiac Surgery, The New England journal of medicine 2005 · PMID 16049209
IN PRACTICE
Ultra-short-acting agents such as esmolol and landiolol offer the effects of
Review · Journal of cardiothoracic and vasc
Ultra-short-acting agents such as esmolol and landiolol offer the effects of beta-blockade without the detrimental effects of long-acting agents, which are hard to counteract once given perioperatively.
Ultra-Short-Acting Β-Blockers (Esmolol and Landiolol) in the Perioperative Period and in Critically Ill Patients, Journal of cardiothoracic and vascular anesthesia 2018 · PMID 29398384
IN PRACTICE
Beta-blocker exposure around major noncardiac surgery was associated with lower
Cohort · JAMA
Beta-blocker exposure around major noncardiac surgery was associated with lower 30-day mortality only in patients with two or more Revised Cardiac Risk Index factors, and only in nonvascular surgery.
Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery, JAMA 2013 · PMID 23613075
THE NUMBERS
Mortality benefit only in the higher-risk, nonvascular patients
Relative risk of 30-day death, propensity-matched.
The same risk-dependence in a second, larger dataset — and confined to nonvascular surgery.
Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery, JAMA 2013 · PMID 23613075
IN PRACTICE
Long-term preoperative beta-blocker prescription is independently associated with
Review · British journal of anaesthesia
Long-term preoperative beta-blocker prescription is independently associated with increased postoperative ischaemic stroke risk at 30 and 365 days, especially in lower-risk patients.
Beta Blockers, Stroke, and Noncardiac Surgery: Resolving an Enduring Perioperative Dilemma, British journal of anaesthesia 2026 · PMID 42290631
IN THE ROOM
What this changes about the next case
Colour is the strength of the evidence behind each step, not the urgency.
1
1
Pooling only the trials whose data remain secure, starting a beta-blocker before noncardiac surgery increased 30-day all-cause mortality by 27%, and increased stroke and hypotension while reducing non-fatal myocardial infarction.
2
2
Starting extended-release metoprolol before noncardiac surgery reduced myocardial infarction from 5.7% to 4.2% but increased death from 2.3% to 3.1% and doubled stroke from 0.5% to 1.0%.
3
3
The association between perioperative beta-blockade and survival tracks baseline risk: benefit appeared at a Revised Cardiac Risk Index of 2 or more, with no benefit and possible harm at a score of 0 or 1.
4
4
Beta-blocker exposure around major noncardiac surgery was associated with lower 30-day mortality only in patients with two or more Revised Cardiac Risk Index factors, and only in nonvascular surgery.
5
5
Ultra-short-acting agents such as esmolol and landiolol offer the effects of beta-blockade without the detrimental effects of long-acting agents, which are hard to counteract once given perioperatively.
The oral-boards stem on the next slide puts these into one scenario.
KEY TAKEAWAYS
What to carry into the next case
Pooling only the trials whose data remain secure, starting a beta-blocker before
Heart (British Cardiac Society) 2014
Starting extended-release metoprolol before noncardiac surgery reduced myocardial
England) 2008
The association between perioperative beta-blockade and survival tracks baseline risk
The New England journal of medicine 2005
Ultra-short-acting agents such as esmolol and landiolol offer the effects of
Journal of cardiothoracic and vascular anesthesia 2018
Pooling only the trials whose data remain secure, starting a beta-blocker before
Questions I'll ask you in the room
How does your plan change if the patient is not optimised?
What is the physiology behind what we just did?
Talk me through the trade-off you made there.
What would make you abandon this plan and do something else?
Oral boards stem
A 68-year-old on long-standing metoprolol for rate control presents for elective hip arthroplasty. He took his dose this morning. A colleague suggests starting a beta-blocker in the patient in the next room, who is not on one but has three cardiac risk factors.
Board questions
1. Name the two ultra-short-acting beta-blockers described for use in the perioperative period and in critically ill patients, and state the specific advantage they are said to have over long-acting beta-blockers once a dose has already been given during a case.
Show answer
Esmolol and landiolol. They offer the effects of beta-blockade without the detrimental effects of long-acting agents, which are hard to counteract once they have been given perioperatively.
The appeal of esmolol and landiolol is that the exposure is short: with a long-acting beta-blocker, once it is in, its effects are hard to counteract for the rest of the case.
Ultra-Short-Acting Β-Blockers (Esmolol and Landiolol) in the Perioperative Period and in Critically Ill Patients, Journal of cardiothoracic and vascular anesthesia 2018 · PMID 29398384
2. In the POISE trial, extended-release metoprolol was started before noncardiac surgery. State what happened to myocardial infarction, death, and stroke, giving the event rates for each, and summarise in one sentence the trade-off the trial demonstrated.
Show answer
Myocardial infarction fell from 5.7% to 4.2%, but death rose from 2.3% to 3.1% and stroke doubled from 0.5% to 1.0%. The trial traded fewer myocardial infarctions for more deaths and twice as many strokes.
POISE is why starting a beta-blocker to prevent infarction is not a free move: the infarctions prevented came alongside more deaths and double the stroke rate.
Effects of Extended-Release Metoprolol Succinate in Patients Undergoing Non-Cardiac Surgery (POISE Trial): A Randomised Controlled Trial, Lancet (London, England) 2008 · PMID 18479744
3. A study of perioperative beta-blocker therapy after major noncardiac surgery analysed survival by Revised Cardiac Risk Index score. Describe how the relationship between beta-blockade and survival varied across the risk spectrum, and state what kind of relationship the study supports.
Show answer
The association between perioperative beta-blockade and survival tracked baseline risk: benefit appeared at a Revised Cardiac Risk Index of 2 or more, with no benefit and possible harm at a score of 0 or 1. It is an association with survival across risk strata, not a demonstrated causal effect of beta-blockade.
Stratify before you generalise: the survival association here sat with a Revised Cardiac Risk Index of 2 or more, and at 0 or 1 it pointed to no benefit and possible harm.
Perioperative Beta-Blocker Therapy and Mortality after Major Noncardiac Surgery, The New England journal of medicine 2005 · PMID 16049209
4. A meta-analysis restricted to the trials of perioperative beta-blockade whose data remain secure pooled outcomes for starting a beta-blocker before noncardiac surgery. State each outcome and its direction, including the mortality figure, and then say what this pooled analysis does not address.
Show answer
Pooling only the trials whose data remain secure, starting a beta-blocker before noncardiac surgery increased 30-day all-cause mortality by 27%, increased stroke and hypotension, and reduced non-fatal myocardial infarction. The analysis is about starting a beta-blocker before surgery, so it does not address patients already established on chronic beta-blockade, and it reports pooled outcomes rather than which individual patients should or should not be treated.
Once the insecure trials are removed, the pooled signal for starting a beta-blocker is a 27% increase in 30-day mortality plus more stroke and hypotension, in exchange for fewer non-fatal infarctions.
Meta-Analysis of Secure Randomised Controlled Trials of Β-Blockade to Prevent Perioperative Death in Non-Cardiac Surgery, Heart (British Cardiac Society) 2014 · PMID 23904357
The bottom linePooling only the trials whose data remain secure, starting a beta-blocker before
Sources
[1] Meta-Analysis of Secure Randomised Controlled Trials of Β-Blockade to Prevent Perioperative Death in Non-Cardiac Surgery, Heart (British Cardiac Society) 2014 · PMID 23904357 open
[2] Effects of Extended-Release Metoprolol Succinate in Patients Undergoing Non-Cardiac Surgery (POISE Trial): A Randomised Controlled Trial, Lancet (London, England) 2008 · PMID 18479744 open
[3] Perioperative Beta-Blocker Therapy and Mortality after Major Noncardiac Surgery, The New England journal of medicine 2005 · PMID 16049209 open
[4] Ultra-Short-Acting Β-Blockers (Esmolol and Landiolol) in the Perioperative Period and in Critically Ill Patients, Journal of cardiothoracic and vascular anesthesia 2018 · PMID 29398384 open
[5] Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery, JAMA 2013 · PMID 23613075 open
[6] Beta Blockers, Stroke, and Noncardiac Surgery: Resolving an Enduring Perioperative Dilemma, British journal of anaesthesia 2026 · PMID 42290631 open