POISE: Beta-blockers on the day of surgery

In the second of his series of the most influential randomised controlled trials in anaesthesia, Dr Jeremy Fabes appraises the trial that answered the question of whether to give patients beta-blockers on the day of their operation.

 

Beta-blockers on the day of surgery

Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial; POISE Study Group, Lancet 2008; 371: 1839–47.

Background

This study tries to provide a definitive resolution to conflicting results from previous work on perioperative beta-blockade that showed a reduction in perioperative MI but increased risk of cardiogenic shock and death

Evidence in support from DECREASE trials – supported bisoprolol 7-21 days before surgery

– Discredited 2011 – lack of consent, poor data collection and fabrication

No large trial of beta blockers on the day of surgery

 

Methods

Multicenter, parallel-group, randomized, placebo-controlled trial in 23 countries (2002-2007)

Randomized over 8,000 patients to metoprolol or placebo on the day of surgery

Adult patients undergoing non-cardiac surgery expected to remain in hospital over 24hrs

Atherosclerotic disease or risk factors for cardiac events

Cardiovascular outcomes at 30 days – CV death, non-fatal MI and non-fatal cardiac arrest

 

Outcomes

Beta-blockers caused a significant reduction in primary composite outcome (5.8% vs. 6.9%) and peri-op MI (4.2% vs. 5.7%) but this benefit was more than nullified by higher rate of death (3.1% vs. 2.3%) and stroke (1% vs. 0.5%). There were significant increases in the rates of hypotension and bradycardia intra-operatively.

The study was severely criticised for its blanket use of high-dose metoprolol (100mg pre-op, continued at 200mg after for 30d) as possibly more strokes and deaths were due to post-operative hypotension.

 

Meta-analysis

A number of meta-analyses have been performed, often with exclusion of DECREASE (outlier, few events, heterogeneity)

Meta-analysis in 2014 as part of US guideline development confirmed POISE findings.

 

Impact

2014 US and EU joint society guidelines for evaluation and management for non-cardiac surgery

– Continue chronic beta blockers

– Intermediate/high-risk of myocardial ischemia – consider initiating perioperative beta blockers

– Decision on a case-by-case basis

Do not start beta blockers on the day of surgery.

 

Summary by Dr Jeremy Fabes

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