ArticlesPerioperative β blockers in patients having non-cardiac surgery: a meta-analysis
Introduction
The 2007 update on perioperative β blocker therapy in the American College of Cardiology and American Heart Association (ACC/AHA) guidelines for perioperative cardiovascular assessment for non-cardiac surgery recommends β blockers for patients already on therapy or who are having vascular surgery and have ischaemia on preoperative testing (class I) and for those having vascular surgery or intermediate or high-risk non-vascular surgery with high risk for coronary disease or those with established disease (class II).1 Consequently, the Physicians Consortium for Performance Improvement and the Surgical Care Improvement Project both recommend perioperative β blockade.2
Some randomised trials do not support recommendations in the guidelines and have shown no beneficial effect of perioperative β blockade.3, 4, 5 Despite these findings, the most recent ACC/AHA guideline update in 2007 states that “although many of the randomised controlled trials of β blocker therapy are small, the weight of evidence—especially in aggregate—suggests a benefit to perioperative β blockade during non-cardiac surgery in high-risk patients”.1 In the recently published, landmark POISE (perioperative ischaemic evaluation) trial,6 perioperative metoprolol was associated with a 30% reduction in non-fatal myocardial infarction at the expense of 33% increased risk of all-cause mortality and a 117% increased risk of stroke.
We aimed to critically review the evidence for perioperative β blockers in patients undergoing non-cardiac surgery.
Section snippets
Search strategy and selection criteria
We searched Pubmed, Embase, and the Cochrane Library with the terms “β adrenergic blockers”, “adrenergic β antagonist”, “β blockers”, “perioperative”, “preoperative”, and “intraoperative”. We restricted our search to studies in human beings from January, 1966, to May, 2008. We checked the reference lists of identified articles, previous meta-analyses, and original studies identified by the electronic search to find other potentially eligible studies. There was no language restriction for the
Results
We identified 112 randomised controlled trials, of which 73 were retrieved for detailed assessment (figure 1). We excluded 40 trials—36 of which did not evaluate outcomes of interest, one that was a small subgroup analysis from a larger non surgical cohort,18 and three that were multiple publications from the same dataset19, 20, 21—leaving 33 trials that fulfilled our inclusion criteria.
Table 1 and the webtable summarise the baseline characteristics, and quality assessment, respectively. The 33
Discussion
Our meta-analysis of randomised controlled trials in patients having non-cardiac surgery showed no clear benefit of perioperative β blockers compared with control for the prevention of cardiovascular outcomes. For the overall cohort, we estimate that treatment of 1000 patients with β blockers results in 16 fewer non-fatal myocardial infarctions in survivors but at the expense of three disabling strokes, 45 patients with clinically significant perioperative bradycardia, 59 with hypotension, and
References (54)
- et al.
ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)
J Am Coll Cardiol
(2007) - et al.
The effects of perioperative beta-blockade: results of the metoprolol after vascular surgery (MaVS) study, a randomized controlled trial
Am Heart J
(2006) - et al.
Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses
Lancet
(1999) - et al.
Trial sequential analysis reveals insufficient information size and potentially false positive results in many meta-analyses
J Clin Epidemiol
(2008) - et al.
Trial sequential analysis may establish when firm evidence is reached in cumulative meta-analysis
J Clin Epidemiol
(2008) - et al.
Propranolol for the prevention of postoperative arrhythmias in general thoracic surgery
Ann Thorac Surg
(1999) - et al.
Metoprolol decreases the amount of halothane required to induce hypotension during general anaesthesia
Br J Anaesth
(1986) - et al.
Lessons learned from a randomised controlled study of perioperative beta blockade in high risk patients undergoing emergency surgery
Surgeon
(2006) - et al.
Perioperative metoprolol reduces the frequency of atrial fibrillation after thoracotomy for lung resection
J Cardiothorac Vasc Anesth
(1997) - et al.
Haemodynamic effects of pretreatment with metoprolol in hypertensive patients undergoing surgery
Br J Anaesth
(1986)
Risk of myocardial ischaemia during anaesthesia in treated and untreated hypertensive patients
Br J Anaesth
Bolus administration of esmolol for controlling the hemodynamic response to laryngoscopy and intubation: efficacy and effects on myocardial performance
J Cardiothorac Anesth
Effects of nadolol on arrhythmias during laparoscopy performed under general anaesthesia
Br J Anaesth
Effect of labetalol or lidocaine on the hemodynamic response to intubation: a controlled randomized double-blind study
J Clin Anesth
Attenuation of the hemodynamic responses to endotracheal intubation with preinduction intravenous labetalol
J Clin Anesth
Methohexitone anaesthesia for microlaryngoscopy: circulatory modulation with metoprolol and dihydralazine
Br J Anaesth
The influence of perioperative myocardial infarction on long-term prognosis following elective vascular surgery
Chest
Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis
Lancet
ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)
Circulation
Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial
J Vasc Surg
Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial
BMJ
Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial
Lancet
Cochrane handbook for systematic reviews of interventions version 5.0.0 edn
Sbe24: metan—an alternative meta-analysis command
Stata Technical Bull Reprints
A note on graphical presentation of estimated odds ratios from several clinical trials
Stat Med
Much ado about nothing: a comparison of the performance of meta-analytical methods with rare events
Stat Med
What to add to nothing? Use and avoidance of continuity corrections in meta-analysis of sparse data
Stat Med
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