Perioperative beta-blockade: might the baby go out with the bath water?

Perioperative beta-blocker therapy has been advocated to reduce cardiac mortality and morbidity in high-risk cardiac patients undergoing non-cardiac surgery. Core data that supported this intervention and informed international societal guidelines has recently been withdrawn. A subsequent meta-analysis of the remaining data reporting excess mortality has re-opened the debate about the utility of beta-blocker therapy in the perioperative period. Criticism of remaining trial designs and new insights into the protective mechanisms of beta-blocker therapy in critical illness raise important questions that should now be addressed by a further robust, high-quality randomised control trial.