BMH open access with impressive meta-analysis on the use of perioperative b-blockade to prevent deaths in non-cardiac surgery(see http://dx.doi.org/10.1136/heartjnl-2013-304262). the issue here is that much of the push for b-blockade came from profound mortality benefit found in the DECREASE family of trials (6 dutch trials, which have largely been conclusively discredited because of “fictitious methods”, “factitious adjudication committee”, and in one case “the entire study dataset had been fabricated”). even though these trials were exposed and discredited 2 years ago, the European Society of Cardiology and American Heart Association guidelines still endorse periop b-blockade; 2009 recs for AHA is to initiate perioperative b-blockage with dose titration in pts undergoing vascular and ischemia on pre-op testing, vascular surgery and established CAD, vascular surgery and more than one risk factor, and intermediate-risk surgery and CAD or more than one risk factor. the meta-analysis:
–11 RCTs met eligibility criteria, using bisoprolol, metoprolol, atenolol and propranolol. some diff on when ititiated b-blockers — from 37 days to 30 min prior to surgery and continued 5 to 30 days after.
–10,529 pts in 9 trials assessed all-cause mortality and found 162 deaths in 5264 pts on b-blockers and 129 in 5265 pts on placebo (increased mortality of 27%), with little heterogeneity between trials
–6 RCTs assessed MI — 27% decrease in non-fatal MI with b-blockade, BUT 73% increase in stroke and 51% increase in hypotension. (i sent out the POISE trial a couple of years ago: see orDOI:10.1016/S0140-6736(08)60601-7, which was by far the largest, well-done trial of the group, finding dramatic increase in strokes)
–so, by the authors calculation: refraining from the european cardiol guidelines would likely prevent up to 10K iatrogenic deaths/yr in the UK)
so, though we don’t have all the data we would like (eg, the studies included wide range of surgeries, such as abd, ortho, urolog, gynecolog, plastic — so not sure if benefit might be different with different surgeries), we are likely traversing the “do no harm” boundary. the issue for us guys is that the guidelines, though old and predating the rather striking exposure of the DECREASE trials, are still standing and it is often hard for primary care or surgeons to buck them. for example, i had a patient a couple of years ago, for whom the surgeon insisted on b-blockers even though i sent him the POISE study, so i had to do it to have the surgery done… ie, we need updated guidelines.
also, when looking at outcomes, all are not equal. i, personally, would prefer a nonfatal MI to a stroke.
geoff