Background:
The 2007 ACC/AHA guideline on perioperative evaluation recommends perioperative β-blockers for non-cardiac surgery. However, some clinical trials seem to be at odds with these recommendations.
Methods:
PUBMED/EMBASE/CENTRAL search for randomized trials (RCTs) evaluating β-blockers for non-cardiac surgery. Efficacy outcomes of all-cause mortality, cardiovascular (CV) mortality, nonfatal MI, nonfatal stroke, heart failure, and myocardial ischemia (30 days), and safety outcomes of perioperative bradycardia, hypotension, and bronchospasm.
Results:
Among 33 RCTs which evaluated 12,306 patients, β-blockers were not associated with any significant reduction in the risk of all-cause mortality, CV mortality, or heart failure, but were associated with a 35% decrease in nonfatal MI, 64% decrease in myocardial ischemia at the expense of a 101% increase (Figure
) in nonfatal strokes. The beneficial effects were driven mainly by trials with high-bias risk, while analyses of low-biased trials showed a 28% and 101% increase in all-cause mortality and stroke with only a 29% and 59% reduction in nonfatal MI and 59%myocardial ischemia. For the safety outcomes, β-blockers were associated with a significantly increased risk of peri-op bradycardia and peri-op hypotension.
Conclusions:
In patients undergoing non-cardiac surgery, we estimate that treatment of 1000 patients with β-blockers results in 16 fewer nonfatal MI, but at the expense of 3 disabling strokes and 45 and 59 patients with clinically significant perioperative bradycardia and hypotension respectively, and suggests an increase in all-cause mortality.
Pulmonary hemodynamics and effects of phosphodiesterase type 5 inhibition in heart failure: a meta-analysis of randomized trials
