The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.

Letter to the Editor

Editor, – It was disappointing to read that beta blockers have fallen from favour for the treatment of hypertension (Aust Prescr 2007;30:5-7), particularly at a time when their use as prophylaxis for myocardial ischaemia in the perioperative period is being encouraged.

Myocardial ischaemia related to surgical stress often occurs in patients with no history of coronary artery disease. It is also frequently silent, but causes significant cardiac morbidity and mortality.

Beta blockers are effective prophylaxis for high risk patients1 and are recommended by the American College of Cardiology/American Heart Association guideline for perioperative cardiovascular evaluation for noncardiac surgery.2

The benefit and risk of prophylactic beta blockade in low to moderate risk patients is less clear. The POISE trial, which is currently recruiting 10 000 patients, should soon provide some definitive recommendations.3

Beta blockers may not be as effective at achieving target blood pressure as other classes of antihypertensive drugs. However, in the perioperative setting beta blockers should remain first-line therapy for blood pressure control, particularly when risk factors for ischaemic heart disease are present.

James French
Consultant anaesthetist
The Canberra Hospital

Authors' comments

Dr Maros Elsik and Professor Henry Krum, authors of the article, comment:

In patients with cardiovascular comorbidities or complications as a result of hypertension, treatment needs to be individualised. In many such cases beta blockers are a reasonable option.

Their use in the perioperative setting, although not specifically discussed in our article, has been shown to improve cardiovascular outcomes mainly by reducing myocardial ischaemic events. This represents another situation where beta blockers should not necessarily be stopped or avoided.


  1. Lindenauer PK, Pekow P, Wang K, Mamidi DK, Gutierrez B, Benjamin EM. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med 2005;353:349-61.
  2. Eagle K, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, et al; American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery. Circulation 2002;105:1257-67.
  3. Devereaux PJ, Yang H, Guyatt GH, Leslie K, Villar JC, Monteri VM; POISE Trial Investigators. Rationale, design, and organization of the PeriOperative ISchemic Evaluation (POISE) trial: a randomized controlled trial of metoprolol versus placebo in patients undergoing noncardiac surgery. Am Heart J 2006;152:223-30.