1150 www.anesthesia-analgesia.org April 2018 • Volume 126 • Number 4 DOI: 10.1213/ANE.0000000000002804 A s the population ages, surgery is required more fre- quently to treat common elective (eg, joint replace- ment due to osteoarthritis) and emergent (eg, repair of colonic perforation due to diverticular disease) conditions associated with age. 1–20 The risk of perioperative adverse events is higher among patients with known coronary artery KEY POINTS • Question: Does the impact of perioperative metoprolol on perioperative outcomes of mortality, myocardial infarction, and stroke vary according to age? • Findings: In reviewing the results of the POISE trial (8351 patients, metoprolol continuous release 200 mg daily for 30 days versus placebo), we found no differences in effect between older and younger individuals for any outcome. • Meaning: The effect of perioperative metoprolol on reducing myocardial infarction, and likely increasing stroke and death, is probably similar in older and younger individuals. BACKGROUND: Perioperative β-blockade reduces the incidence of myocardial infarction but increases that of death, stroke, and hypotension. The elderly may experience few benefts but more harms associated with β-blockade due to a normal effect of aging, that of a reduced rest- ing heart rate. The tested hypothesis was that the effect of perioperative β-blockade is more signifcant with increasing age. METHODS: To determine whether the effect of perioperative β-blockade on the primary compos- ite event, clinically signifcant hypotension, myocardial infarction, stroke, and death varies with age, we interrogated data from the perioperative ischemia evaluation (POISE) study. The POISE study randomly assigned 8351 patients, aged ≥45 years, in 23 countries, undergoing major noncardiac surgery to either 200 mg metoprolol CR daily or placebo for 30 days. Odds ratios or hazard ratios for time to events, when available, for each of the adverse effects were measured according to decile of age, and interaction term between age and treatment was calculated. No adjustment was made for multiple outcomes. RESULTS: Age was associated with higher incidences of the major outcomes of clinically signif- cant hypotension, myocardial infarction, and death. Age was associated with a minimal reduc- tion in resting heart rate from 84.2 (standard error, 0.63; ages 45–54 years) to 80.9 (standard error, 0.70; ages >85 years; P < .0001). We found no evidence of any interaction between age and study group regarding any of the major outcomes, although the limited sample size does not exclude any but large interactions. CONCLUSIONS: The effect of perioperative β-blockade on the major outcomes studied did not vary with age. Resting heart rate decreases slightly with age. Our data do not support a recommen- dation for the use of perioperative β-blockade in any age subgroup to achieve benefts but avoid harms. Therefore, current recommendations against the use of β-blockers in high-risk patients undergoing noncardiac surgery apply across all age groups. (Anesth Analg 2018;126:1150–7) Age Does Not Affect Metoprolol’s Effect on Perioperative Outcomes (From the POISE Database) Michael J. Jacka, MD, MSc, MBA,* Gordon Guyatt, MD, MSc,† Richard Mizera, MD,† Janet Van Vlymen, MD,‡ Dario Ponce de Leon, MD,§ Thomas Schricker, MD,∥ Mohd Yani Bahari, MD,¶ Bonan Lv, MD,# Lalitha Afzal, MD,** Maria Pilar Plou García, MD,†† Xinmin Wu, MD,‡‡ Lília Nigro Maia, MD,§§ Maribel Arrieta, MD,∥∥ Purnima Rao-Melacini, MSc,¶¶ and Philip J. Devereaux, MD, PhD† From the *Department of Anesthesiology and Critical Care, University of Alberta, Edmonton, Alberta, Canada; †Department of Medicine, McMaster University, Hamilton, Ontario, Canada; ‡Department of Anesthesiology, Queen’s University, Kingston, Ontario, Canada; §Department of Anesthesiology, Hospital Nacional Almenara, Lima, Peru; ∥Department of Anesthesiology, McGill University, Montreal, Quebec, Canada; ¶Department of Medicine, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia; #Department of Surgery, Heibei People’s Hospital, Shijiazhuang, China; **Department of Medicine, Christian Medical College, Ludhiana, India; ††Department of Medicine, Hospital Donostia, Guipuzcoa, Spain; ‡‡Department of Surgery, First Hospital, Beijing University, Beijing, China; Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society. This is an open- access article distributed under the terms of the Creative Commons Attribu- tion-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without per- mission from the journal. §§Hospital de Base Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, Brazil; ∥∥Department of Medicine, Hospital Militar Central, Bogota, Columbia; and ¶¶Population Health Research Institute, Hamilton, Ontario, Canada. Accepted for publication November 1, 2017. Institutional ethics board: Health Research Ethics Board, WCM Health Sciences Centre, University of Alberta Hospital, 8440 112 St, Edmonton, AB T6G 2B7. Funding: None. The authors declare no conficts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Michael J. Jacka, MD, MSc, MBA, Department of Anesthesiology and Critical Care, University of Alberta, Edmonton, AB, Canada. Address e-mail to mjacka@ualberta.ca. Section Editor: Tong J. Gan Ambulatory Anesthesiology