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  3. How strong is the evidence for the use of perioperative β blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials
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How strong is the evidence for the use of perioperative β blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.38503.623646.8F (Published 04 August 2005) Cite this as: BMJ 2005;331:313
  1. P J Devereaux1, assistant professor (philipj{at}mcmaster.ca),
  2. W Scott Beattie4, associate professor,
  3. Peter T-L Choi5, assistant professor,
  4. Neal H Badner, associate professor6,
  5. Gordon H Guyatt, professor1,
  6. Juan C Villar7, assistant professor,
  7. Claudio S Cinà2, associate professor,
  8. Kate Leslie, associate professor8,
  9. Michael J Jacka, assistant professor9,
  10. Victor M Montori10, assistant professor,
  11. Mohit Bhandari, assistant professor2,
  12. Alvaro Avezum, research director11,
  13. Alexandre B Cavalcanti11, intensivist,
  14. Julian W Giles12, honorary research fellow,
  15. Thomas Schricker13, assistant professor,
  16. Homer Yang14, professor,
  17. Carl-Johan Jakobsen15, associate professor,
  18. Salim Yusuf, professor3
  1. 1 Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
  2. 2 Department of Surgery and Clinical Epidemiology and Biostatistics, McMaster University
  3. 3 Department of Medicine and Population Health Research Institute, McMaster University
  4. 4 Department of Anesthesia, University of Toronto, Toronto, ON, Canada
  5. 5 Vancouver Coastal Health Research Institute and Department of Anesthesia, University of British Columbia, Vancouver, BC, Canada
  6. 6 Departments of Anesthesiology and Perioperative Medicine, University of Western Ontario, London, ON, Canada
  7. 7 Grupo de Cardiología Preventiva, Universidad Autonoma de Bucaramanga, Colombia
  8. 8 Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
  9. 9 Departments of Anesthesiology and Critical Care, University of Alberta, Edmonton, AB, Canada
  10. 10 Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
  11. 11 Dante Pazzanese Institute of Cardiology and the Albert Einstein Hospital, S~o Paulo, Brazil
  12. 12 Nuffield Department of Anaesthetics, University of Oxford
  13. 13 Department of Anesthesia, McGill University, Montreal, QC, Canada
  14. 14 Department of Anesthesia, University of Ottawa, Ottawa, ON, Canada
  15. 15 Department of Anaesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
  1. Correspondence to: P J Devereaux
  • Accepted 19 May 2005

Abstract

Objective To determine the effect of perioperative β blocker treatment in patients having non-cardiac surgery.

Design Systematic review and meta-analysis.

Data sources Seven search strategies, including searching two bibliographic databases and hand searching seven medical journals.

Study selection and outcomes We included randomised controlled trials that evaluated β blocker treatment in patients having non-cardiac surgery. Perioperative outcomes within 30 days of surgery included total mortality, cardiovascular mortality, non-fatal myocardial infarction, non-fatal cardiac arrest, non-fatal stroke, congestive heart failure, hypotension needing treatment, bradycardia needing treatment, and bronchospasm.

Results Twenty two trials that randomised a total of 2437 patients met the eligibility criteria. Perioperative β blockers did not show any statistically significant beneficial effects on any of the individual outcomes and the only nominally statistically significant beneficial relative risk was 0.44 (95% confidence interval 0.20 to 0.97, 99% confidence interval 0.16 to 1.24) for the composite outcome of cardiovascular mortality, non-fatal myocardial infarction, and non-fatal cardiac arrest. Methods adapted from formal interim monitoring boundaries applied to cumulative meta-analysis showed that the evidence failed, by a considerable degree, to meet standards for forgoing additional studies. The individual safety outcomes in patients treated with perioperative β blockers showed a relative risk for bradycardia needing treatment of 2.27 (95% CI 1.53 to 3.36, 99% CI 1.36 to 3.80) and a nominally statistically significant relative risk for hypotension needing treatment of 1.27 (95% CI 1.04 to 1.56, 99% CI 0.97 to 1.66).

Conclusion The evidence that perioperative β blockers reduce major cardiovascular events is encouraging but too unreliable to allow definitive conclusions to be drawn.

Footnotes

  • Contributors PJD contributed to the concept and design, data acquisition, data analysis, and interpretation of the data; wrote the first draft of the manuscript; critically revised the manuscript; and gave final approval of the submitted manuscript. WSB, PT-LC, NHB, VMM, and C-JJ contributed to the concept and design, data acquisition, and interpretation of data; critically revised the manuscript; and gave final approval of the submitted manuscript. VMM contributed to the concept and design, data analysis, and interpretation of data; critically revised the manuscript; and gave final approval of the submitted manuscript. GHG, JCV, CSC, KL, MJJ, MB, AA, ABC, JWG, TS, HY, and SY contributed to the concept and design and interpretation of the data; critically revised the manuscript; and gave final approval of the submitted manuscript. PJD is the guarantor.

  • Funding PJD is supported by a Canadian Institutes of Health Research senior research fellowship award. WSB is the R Fraser Elliot Chair of Cardiac Anesthesia and is supported by the Toronto General and Western Foundations and the University Health Network, University of Toronto. PT-LC is supported by a Vancouver Coastal Health Research Institute mentored clinician scientist award. JCV is supported by a Heart and Stroke Foundation of Canada doctoral research award. VMM is a Mayo Foundation scholar. MB is supported by the Detweiler Fellowship from the Royal College of Physicians and Surgeons of Canada, and a Department of Clinical Epidemiology and Biostatistics, McMaster University, clinical scientist fellowship award. JWG is supported by a Department of Anesthesia, Oxford University, research fellowship award. SY holds an endowed chair of the Heart and Stroke Foundation of Ontario and is a senior scientist of the Canadian Institutes of Health Research.

  • Competing interests PJD, WSB, PT-LC, NHB, GHG, JCV, CSC, KL, MJJ, VMM, AA, ABC, JWG, TS, HY, and SY are all members of the POISE trial. SY has received honorariums and research grants from AstraZeneca, which manufactures metoprolol CR.

  • Accepted 19 May 2005
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