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
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
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
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.
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.
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