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Meta-analysis of secure randomised controlled trials of beta-blockade to prevent perioperative death in non-cardiac surgery

Title: Meta-analysis of secure randomised controlled trials of beta-blockade to prevent perioperative death in non-cardiac surgery
Authors: Bouri, S
Shun-Shin, MJ
Cole, GD
Mayet, J
Francis, DP
Item Type: Journal Article
Abstract: Background Current European and American guidelines recommend the perioperative initiation of a course of β-blockers in those at risk of cardiac events undergoing high- or intermediate-risk surgery or vascular surgery. The Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) family of trials, the bedrock of evidence for this, are no longer secure. We therefore conducted a meta-analysis of randomised controlled trials of β-blockade on perioperative mortality, non-fatal myocardial infarction, stroke and hypotension in non-cardiac surgery using the secure data. Methods The randomised controlled trials of initiation of β-blockers before non-cardiac surgery were examined. Primary outcome was all-cause mortality at 30 days or at discharge. The DECREASE trials were separately analysed. Results Nine secure trials totalling 10 529 patients, 291 of whom died, met the criteria. Initiation of a course of β-blockers before surgery caused a 27% risk increase in 30-day all-cause mortality (p=0.04). The DECREASE family of studies substantially contradict the meta-analysis of the secure trials on the effect of mortality (p=0.05 for divergence). In the secure trials, β-blockade reduced non-fatal myocardial infarction (RR 0.73, p=0.001) but increased stroke (RR 1.73, p=0.05) and hypotension (RR 1.51, p<0.00001). These results were dominated by one large trial. Conclusions Guideline bodies should retract their recommendations based on fictitious data without further delay. This should not be blocked by dispute over allocation of blame. The well-conducted trials indicate a statistically significant 27% increase in mortality from the initiation of perioperative β-blockade that guidelines currently recommend. Any remaining enthusiasts might best channel their energy into a further randomised trial which should be designed carefully and conducted honestly.
Issue Date: 15-Mar-2014
Date of Acceptance: 12-Jul-2013
URI: http://hdl.handle.net/10044/1/61359
DOI: https://dx.doi.org/10.1136/heartjnl-2013-304262
ISSN: 1355-6037
Publisher: BMJ Publishing Group
Start Page: 456
End Page: 464
Journal / Book Title: Heart
Volume: 100
Issue: 6
Copyright Statement: © The Author(s). This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/
Sponsor/Funder: British Heart Foundation
British Heart Foundation
British Heart Foundation
Funder's Grant Number: FS/10/38/28268
FS/12/12/29294
FS/14/27/30752
Keywords: Science & Technology
Life Sciences & Biomedicine
Cardiac & Cardiovascular Systems
Cardiovascular System & Cardiology
HIGH-RISK PATIENTS
VASCULAR-SURGERY
MYOCARDIAL-ISCHEMIA
CARDIAC MORTALITY
DECREASE-IV
CR ZOK
METOPROLOL
BISOPROLOL
BLOCKERS
FLUVASTATIN
MYOCARDIAL ISCHAEMIA AND INFARCTION (IHD)
Adrenergic beta-Antagonists
Cardiovascular Diseases
Global Health
Humans
Postoperative Complications
Preoperative Care
Randomized Controlled Trials as Topic
Survival Rate
Vascular Surgical Procedures
1102 Cardiovascular Medicine And Haematology
Cardiovascular System & Hematology
Publication Status: Published
Online Publication Date: 2013-07-31
Appears in Collections:National Heart and Lung Institute
Faculty of Medicine



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