Stopping Beta-Blockers After Coronary Artery Bypass Surgery

(DROP-BB Trial)

Overseen by Arnar Geirsson, MD

Age: 18+

Sex: Any

Travel: May Be Covered

Time Reimbursement: Varies

Trial Phase: Academic

Recruiting

Sponsor: Yale University

Disqualifiers: Combined valve, aorta surgery, others

No Placebo Group

Trial Summary

What is the purpose of this trial?

This trial is testing if stopping beta-blocker medication after heart bypass surgery can help patients exercise better and feel less tired, while still keeping them safe from serious heart and brain problems.

Will I have to stop taking my current medications?

The trial is specifically about stopping beta-blocker medication after coronary artery bypass surgery, so you may need to stop taking beta-blockers if you are currently on them. The protocol does not specify about other medications.

What data supports the effectiveness of stopping the drug beta-blockers after coronary artery bypass surgery?

The research does not provide direct evidence on the effectiveness of stopping beta-blockers after coronary artery bypass surgery. However, beta-blockers are generally associated with improved outcomes in patients with cardiovascular disease, suggesting that their continuation might be beneficial. ^{1 2 3 4 5}

Is it safe to stop taking beta-blockers after coronary artery bypass surgery?

Research on beta-blockers in surgery shows they can reduce heart complications, but stopping them suddenly might increase risks. One study found that intravenous beta-blockers caused more side effects like low blood pressure compared to oral ones. It's important to consult with a doctor before making any changes to beta-blocker use after surgery. ^{1 5 6 7 8}

How does stopping beta-blockers after coronary artery bypass surgery differ from other treatments?

Stopping beta-blockers after coronary artery bypass surgery is unique because it involves discontinuing a medication that is typically used to protect the heart during and after surgery. This approach contrasts with the common practice of maintaining beta-blocker therapy to reduce the risk of heart injury and improve survival rates. ^{1 5 9 10 11}

Research Team

Makoto Mori, MD

Principal Investigator

Yale University

Arnar Geirsson, MD

Principal Investigator

Yale University

Eligibility Criteria

This trial is for patients who had coronary artery bypass surgery at Yale New Haven Hospital, showed up for their 1-month post-op visit, have a heart pumping strength (ejection fraction) over 50%, and were in normal heart rhythm when leaving the hospital or joining the study. It's not for those who had additional valve or aorta surgeries along with their bypass.

Inclusion Criteria

I had CABG surgery at Yale New Haven Hospital, left with a good heart pump function, and a normal heart rhythm.

Exclusion Criteria

I have had surgery on my aorta and bypass surgery.

I had surgery for both heart valve and bypass.

Trial Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants undergo coronary artery bypass grafting (CABG) and are randomized to either continue or withdraw beta-blocker medication. Medication changes occur at the 1-month clinic visit.

1 month

1 visit (in-person)

Follow-up

Participants are monitored for exercise capacity, MACCE, and fatigue-related symptoms. Phone follow-ups are conducted to ensure medication adherence and adjudicate endpoints.

12 months

Phone follow-ups

Treatment Details

Interventions

• Discontinuing all beta-blocker (Beta-blocker)

Trial Overview The study is looking into what happens if you stop taking beta-blocker meds after having coronary artery bypass surgery. Patients are randomly chosen to either keep taking or stop their beta-blockers to see how it affects them.

Participant Groups

Group I: Withdrawing of beta-blockers Experimental Treatment 1 Intervention

Discontinuation of all BB, and medication changes will be made at the 1-month clinic visit. A cardiopulmonary exercise test (CPET) will be performed 1 month after the randomization (2 months after CABG).

Group II: Continuation of beta-blocker regimen Active Control 1 Intervention

Participants will continue with current standard of care on current beta-blocker regimen

Who Is Running the Clinical Trial?

Yale University

Lead Sponsor

Trials

1,963

Recruited

3,046,000+

Nancy J. Brown

Yale University

Chief Medical Officer since 2020

MD from Yale School of Medicine

Peter Salovey

Yale University

Chief Executive Officer since 2013

PhD in Psychology from Yale University

Glenn Memorial Fund

Collaborator

Trials

1

Recruited

410+

Findings from Research

In a study of 140 patients undergoing major vascular surgery, those who had their beta-blockers discontinued postoperatively experienced a significantly higher mortality rate of 50% compared to just 1.5% in those who continued the medication.

The discontinuation of beta-blockers was also linked to a higher risk of cardiovascular events, including a 29% rate of cardiovascular mortality and a 17.7 times greater likelihood of postoperative myocardial infarction, indicating that continuing beta-blockers after surgery may be crucial for patient safety.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Perioperative beta-blocker withdrawal and mortality in vascular surgical patients. Shammash, JB., Trost, JC., Gold, JM., et al.[2006]

In a study of 4381 patients undergoing coronary artery bypass grafting (CABG), preoperative beta-blocker therapy was associated with a significant reduction in post-operative stroke risk, with an adjusted odds ratio of 0.59.

However, patients receiving beta-blockers experienced a higher incidence of atrial arrhythmias, indicating a potential trade-off in benefits and risks, while there were no significant differences in operative mortality or other morbidity outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Preoperative beta-blocker therapy in coronary artery bypass surgery: a propensity score analysis of outcomes. Srinivasan, AK., Shackcloth, MJ., Grayson, AD., et al.[2022]

In a study of 50,281 patients who underwent laparoscopic gastric bypass surgery, preoperative beta-blocker therapy did not significantly affect the rates of postoperative complications or mortality within 90 days and 1 year after surgery.

However, patients on beta-blockade experienced slightly greater weight loss two years post-surgery, suggesting a potential benefit in long-term outcomes despite limited impact on immediate postoperative results.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Limited Effect of Beta-blockade on Postoperative Outcome After Laparoscopic Gastric Bypass Surgery. Stenberg, E., Mohseni, S., Cao, Y., et al.[2020]

Beta-blockers are beneficial for patients undergoing coronary artery bypass graft (CABG) surgery, particularly in reducing mortality rates and the incidence of new-onset postoperative atrial fibrillation, especially in those with a history of myocardial infarction or congestive heart failure.

Among the various beta-blockers, carvedilol has shown the most significant benefits for CABG patients, and nearly all patients without contraindications should receive perioperative beta-blocker therapy.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Rationale for administering beta-blocker therapy to patients undergoing coronary artery bypass surgery: a systematic review. Thaper, A., Kulik, A.[2023]

In a study involving 107 patients undergoing major vascular surgery, the use of the beta-blocker atenolol significantly reduced cardiac complications from 10 cases in the control period to just 1 case after its introduction (P=0.01).

The analysis indicated that beta-blocker treatment was strongly associated with decreased cardiac morbidity, with an odds ratio of 0.12, suggesting it is an effective and safe intervention for preventing cardiac issues in these patients, despite two cases of bronchospasm leading to discontinuation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Routine beta-blockade in vascular surgery. Torella, F., de Cossart, L., Dimitri, SK., et al.[2022]

In a pilot study of 50 high-risk patients undergoing coronary artery bypass grafting, intravenous esmolol did not reduce the incidence of post-operative atrial fibrillation compared to standard oral beta-blockers, with 26% of patients in both groups developing AF.

However, the intravenous esmolol group experienced significantly more adverse effects, particularly hypotension, in 41% of patients, compared to only 4% in the oral beta-blocker group, suggesting that oral beta-blockers are safer and equally effective for preventing post-operative AF.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Intravenous versus oral beta-blockers for prevention of post-CABG atrial fibrillation in high-risk patients identified by signal-averaged ECG: lessons of a pilot study. Maniar, PB., Balcetyte-Harris, N., Tamis, JE., et al.[2019]

In a meta-analysis of 9 trials involving 10,544 patients undergoing non-cardiac surgery, beta-blockers were associated with a 19% increased risk of all-cause mortality, indicating potential safety concerns in their use.

However, in high-risk surgical patients, beta-blockers significantly reduced the risk of total mortality by 73%, suggesting they may provide protective benefits specifically for those undergoing more dangerous surgeries.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Beta-blockers and risk of all-cause mortality in non-cardiac surgery. Angeli, F., Verdecchia, P., Karthikeyan, G., et al.[2010]

In a study of 29 patients undergoing aorto-coronary bypass surgery, maintaining beta-blocker medication before surgery resulted in less myocardial injury, as indicated by lower levels of S-CK B activity.

Patients who continued beta-blockade and received an additional dose of metoprolol before surgery experienced better heart protection compared to those who had their beta-blockers withdrawn.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Myocardial protective effect of maintained beta-blockade in aorto-coronary bypass surgery. Berggren, H., Ekroth, R., Herlitz, J., et al.[2019]

In a study of over 506,000 patients undergoing nonemergent coronary artery bypass grafting (CABG), preoperative use of β-blockers did not significantly reduce perioperative mortality or other major complications compared to those who did not receive them.

However, patients who received β-blockers within 24 hours of surgery experienced a higher incidence of new-onset atrial fibrillation, suggesting a potential risk associated with their use in this context.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Preoperative β-blocker use in coronary artery bypass grafting surgery: national database analysis. Brinkman, W., Herbert, MA., O'Brien, S., et al.[2014]

In a study examining patients who had their chronic beta-blockade withdrawn after vascular surgery, a significant predictor of in-hospital mortality was an increase in heart rate of six beats per minute or more from surgery to the third postoperative day, with an odds ratio of 13.7.

The findings suggest that monitoring heart rate changes post-surgery could serve as an effective early warning system for identifying patients at higher risk of mortality after beta-blockade withdrawal.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Factors associated with mortality when chronic betablocker therapy is withdrawn in the peri-operative period in vascular surgical patients: a matched case-control study. Biccard, BM.[2021]

References

1. United States pubmed.ncbi.nlm.nih.gov

Perioperative beta-blocker withdrawal and mortality in vascular surgical patients. [2006]

2. England pubmed.ncbi.nlm.nih.gov

Beta blockers and long-term outcome after coronary artery bypass grafting: a nationwide observational study. [2022]

3. England pubmed.ncbi.nlm.nih.gov

Preoperative beta-blocker therapy in coronary artery bypass surgery: a propensity score analysis of outcomes. [2022]

4. United States pubmed.ncbi.nlm.nih.gov

Limited Effect of Beta-blockade on Postoperative Outcome After Laparoscopic Gastric Bypass Surgery. [2020]

5. England pubmed.ncbi.nlm.nih.gov

Rationale for administering beta-blocker therapy to patients undergoing coronary artery bypass surgery: a systematic review. [2023]

6. England pubmed.ncbi.nlm.nih.gov

Routine beta-blockade in vascular surgery. [2022]

7. United States pubmed.ncbi.nlm.nih.gov

Intravenous versus oral beta-blockers for prevention of post-CABG atrial fibrillation in high-risk patients identified by signal-averaged ECG: lessons of a pilot study. [2019]

8. England pubmed.ncbi.nlm.nih.gov

Beta-blockers and risk of all-cause mortality in non-cardiac surgery. [2010]

9. Sweden pubmed.ncbi.nlm.nih.gov

Myocardial protective effect of maintained beta-blockade in aorto-coronary bypass surgery. [2019]

10. United States pubmed.ncbi.nlm.nih.gov

Preoperative β-blocker use in coronary artery bypass grafting surgery: national database analysis. [2014]

11. South Africa pubmed.ncbi.nlm.nih.gov

Factors associated with mortality when chronic betablocker therapy is withdrawn in the peri-operative period in vascular surgical patients: a matched case-control study. [2021]