Perioperative beta blockade in noncardiac surgery

A systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery a report of the American College of Cardiology/American Heart Association task force on practice guidelines

Duminda N. Wijeysundera, Dallas Duncan, Chileshe Nkonde-Price, Salim S. Virani, Jeffrey B. Washam, Kirsten E. Fleischmann, Lee A. Fleisher, Jeffrey L. Anderson, Halperin Jonathan, Nancy M. Albert, Biykem Bozkurt, Ralph G. Brindis, Lesley H. Curtis, David DeMets, Samuel Gidding, Judith S. Hochman, Richard Kovacs, E. Magnus Ohman, Susan Pressler, Frank K. Sellke & 1 others Win Kuang Shen

Research output: Contribution to journalArticle

61 Citations (Scopus)

Abstract

Objective-To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates.

Methods-PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery. Pooled relative risks (RRs) were calculated under the random-effects model. We conducted subgroup analyses to assess how the DECREASE-I (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography), DECREASE-IV, and POISE-1 (Perioperative Ischemic Evaluation) trials influenced our conclusions.

Results-We identified 17 studies, of which 16 were RCTs (12 043 participants) and 1 was a cohort study (348 participants). Aside from the DECREASE trials, all other RCTs initiated beta blockade within 1 day or less prior to surgery. Among RCTs, beta blockade decreased nonfatal myocardial infarction (MI) (RR: 0.69; 95% confidence interval [CI]: 0.58 to 0.82) but increased nonfatal stroke (RR: 1.76; 95% CI: 1.07 to 2.91), hypotension (RR: 1.47; 95% CI: 1.34 to 1.60), and bradycardia (RR: 2.61; 95% CI: 2.18 to 3.12). These findings were qualitatively unchanged after the DECREASE and POISE-1 trials were excluded. Effects on mortality rate differed significantly between the DECREASE trials and other trials. Beta blockers were associated with a trend toward reduced all-cause mortality rate in the DECREASE trials (RR: 0.42; 95% CI: 0.15 to 1.22) but with increased all-cause mortality rate in other trials (RR: 1.30; 95% CI: 1.03 to 1.64). Beta blockers reduced cardiovascular mortality rate in the DECREASE trials (RR: 0.17; 95% CI: 0.05 to 0.64) but were associated with trends toward increased cardiovascular mortality rate in other trials (RR: 1.25; 95% CI: 0.92 to 1.71). These differences were qualitatively unchanged after the POISE-1 trial was excluded.

Conclusions-Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.

Original languageEnglish
Pages (from-to)2246-2264
Number of pages19
JournalCirculation
Volume130
Issue number24
DOIs
StatePublished - Dec 9 2014
Externally publishedYes

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Advisory Committees
Practice Guidelines
Guidelines
Confidence Intervals
Randomized Controlled Trials
Mortality
Bradycardia
Hypotension
Cohort Studies
Stroke
Myocardial Infarction
Stress Echocardiography
PubMed
Morbidity

ASJC Scopus subject areas

  • Physiology (medical)
  • Cardiology and Cardiovascular Medicine
  • Medicine(all)

Cite this

Perioperative beta blockade in noncardiac surgery : A systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery a report of the American College of Cardiology/American Heart Association task force on practice guidelines. / Wijeysundera, Duminda N.; Duncan, Dallas; Nkonde-Price, Chileshe; Virani, Salim S.; Washam, Jeffrey B.; Fleischmann, Kirsten E.; Fleisher, Lee A.; Anderson, Jeffrey L.; Jonathan, Halperin; Albert, Nancy M.; Bozkurt, Biykem; Brindis, Ralph G.; Curtis, Lesley H.; DeMets, David; Gidding, Samuel; Hochman, Judith S.; Kovacs, Richard; Ohman, E. Magnus; Pressler, Susan; Sellke, Frank K.; Shen, Win Kuang.

In: Circulation, Vol. 130, No. 24, 09.12.2014, p. 2246-2264.

Research output: Contribution to journalArticle

Wijeysundera, DN, Duncan, D, Nkonde-Price, C, Virani, SS, Washam, JB, Fleischmann, KE, Fleisher, LA, Anderson, JL, Jonathan, H, Albert, NM, Bozkurt, B, Brindis, RG, Curtis, LH, DeMets, D, Gidding, S, Hochman, JS, Kovacs, R, Ohman, EM, Pressler, S, Sellke, FK & Shen, WK 2014, 'Perioperative beta blockade in noncardiac surgery: A systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery a report of the American College of Cardiology/American Heart Association task force on practice guidelines', Circulation, vol. 130, no. 24, pp. 2246-2264. https://doi.org/10.1161/CIR.0000000000000104
Wijeysundera, Duminda N. ; Duncan, Dallas ; Nkonde-Price, Chileshe ; Virani, Salim S. ; Washam, Jeffrey B. ; Fleischmann, Kirsten E. ; Fleisher, Lee A. ; Anderson, Jeffrey L. ; Jonathan, Halperin ; Albert, Nancy M. ; Bozkurt, Biykem ; Brindis, Ralph G. ; Curtis, Lesley H. ; DeMets, David ; Gidding, Samuel ; Hochman, Judith S. ; Kovacs, Richard ; Ohman, E. Magnus ; Pressler, Susan ; Sellke, Frank K. ; Shen, Win Kuang. / Perioperative beta blockade in noncardiac surgery : A systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery a report of the American College of Cardiology/American Heart Association task force on practice guidelines. In: Circulation. 2014 ; Vol. 130, No. 24. pp. 2246-2264.
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title = "Perioperative beta blockade in noncardiac surgery: A systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery a report of the American College of Cardiology/American Heart Association task force on practice guidelines",
abstract = "Objective-To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates.Methods-PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery. Pooled relative risks (RRs) were calculated under the random-effects model. We conducted subgroup analyses to assess how the DECREASE-I (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography), DECREASE-IV, and POISE-1 (Perioperative Ischemic Evaluation) trials influenced our conclusions.Results-We identified 17 studies, of which 16 were RCTs (12 043 participants) and 1 was a cohort study (348 participants). Aside from the DECREASE trials, all other RCTs initiated beta blockade within 1 day or less prior to surgery. Among RCTs, beta blockade decreased nonfatal myocardial infarction (MI) (RR: 0.69; 95{\%} confidence interval [CI]: 0.58 to 0.82) but increased nonfatal stroke (RR: 1.76; 95{\%} CI: 1.07 to 2.91), hypotension (RR: 1.47; 95{\%} CI: 1.34 to 1.60), and bradycardia (RR: 2.61; 95{\%} CI: 2.18 to 3.12). These findings were qualitatively unchanged after the DECREASE and POISE-1 trials were excluded. Effects on mortality rate differed significantly between the DECREASE trials and other trials. Beta blockers were associated with a trend toward reduced all-cause mortality rate in the DECREASE trials (RR: 0.42; 95{\%} CI: 0.15 to 1.22) but with increased all-cause mortality rate in other trials (RR: 1.30; 95{\%} CI: 1.03 to 1.64). Beta blockers reduced cardiovascular mortality rate in the DECREASE trials (RR: 0.17; 95{\%} CI: 0.05 to 0.64) but were associated with trends toward increased cardiovascular mortality rate in other trials (RR: 1.25; 95{\%} CI: 0.92 to 1.71). These differences were qualitatively unchanged after the POISE-1 trial was excluded.Conclusions-Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.",
author = "Wijeysundera, {Duminda N.} and Dallas Duncan and Chileshe Nkonde-Price and Virani, {Salim S.} and Washam, {Jeffrey B.} and Fleischmann, {Kirsten E.} and Fleisher, {Lee A.} and Anderson, {Jeffrey L.} and Halperin Jonathan and Albert, {Nancy M.} and Biykem Bozkurt and Brindis, {Ralph G.} and Curtis, {Lesley H.} and David DeMets and Samuel Gidding and Hochman, {Judith S.} and Richard Kovacs and Ohman, {E. Magnus} and Susan Pressler and Sellke, {Frank K.} and Shen, {Win Kuang}",
year = "2014",
month = "12",
day = "9",
doi = "10.1161/CIR.0000000000000104",
language = "English",
volume = "130",
pages = "2246--2264",
journal = "Circulation",
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TY - JOUR

T1 - Perioperative beta blockade in noncardiac surgery

T2 - A systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery a report of the American College of Cardiology/American Heart Association task force on practice guidelines

AU - Wijeysundera, Duminda N.

AU - Duncan, Dallas

AU - Nkonde-Price, Chileshe

AU - Virani, Salim S.

AU - Washam, Jeffrey B.

AU - Fleischmann, Kirsten E.

AU - Fleisher, Lee A.

AU - Anderson, Jeffrey L.

AU - Jonathan, Halperin

AU - Albert, Nancy M.

AU - Bozkurt, Biykem

AU - Brindis, Ralph G.

AU - Curtis, Lesley H.

AU - DeMets, David

AU - Gidding, Samuel

AU - Hochman, Judith S.

AU - Kovacs, Richard

AU - Ohman, E. Magnus

AU - Pressler, Susan

AU - Sellke, Frank K.

AU - Shen, Win Kuang

PY - 2014/12/9

Y1 - 2014/12/9

N2 - Objective-To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates.Methods-PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery. Pooled relative risks (RRs) were calculated under the random-effects model. We conducted subgroup analyses to assess how the DECREASE-I (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography), DECREASE-IV, and POISE-1 (Perioperative Ischemic Evaluation) trials influenced our conclusions.Results-We identified 17 studies, of which 16 were RCTs (12 043 participants) and 1 was a cohort study (348 participants). Aside from the DECREASE trials, all other RCTs initiated beta blockade within 1 day or less prior to surgery. Among RCTs, beta blockade decreased nonfatal myocardial infarction (MI) (RR: 0.69; 95% confidence interval [CI]: 0.58 to 0.82) but increased nonfatal stroke (RR: 1.76; 95% CI: 1.07 to 2.91), hypotension (RR: 1.47; 95% CI: 1.34 to 1.60), and bradycardia (RR: 2.61; 95% CI: 2.18 to 3.12). These findings were qualitatively unchanged after the DECREASE and POISE-1 trials were excluded. Effects on mortality rate differed significantly between the DECREASE trials and other trials. Beta blockers were associated with a trend toward reduced all-cause mortality rate in the DECREASE trials (RR: 0.42; 95% CI: 0.15 to 1.22) but with increased all-cause mortality rate in other trials (RR: 1.30; 95% CI: 1.03 to 1.64). Beta blockers reduced cardiovascular mortality rate in the DECREASE trials (RR: 0.17; 95% CI: 0.05 to 0.64) but were associated with trends toward increased cardiovascular mortality rate in other trials (RR: 1.25; 95% CI: 0.92 to 1.71). These differences were qualitatively unchanged after the POISE-1 trial was excluded.Conclusions-Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.

AB - Objective-To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates.Methods-PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery. Pooled relative risks (RRs) were calculated under the random-effects model. We conducted subgroup analyses to assess how the DECREASE-I (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography), DECREASE-IV, and POISE-1 (Perioperative Ischemic Evaluation) trials influenced our conclusions.Results-We identified 17 studies, of which 16 were RCTs (12 043 participants) and 1 was a cohort study (348 participants). Aside from the DECREASE trials, all other RCTs initiated beta blockade within 1 day or less prior to surgery. Among RCTs, beta blockade decreased nonfatal myocardial infarction (MI) (RR: 0.69; 95% confidence interval [CI]: 0.58 to 0.82) but increased nonfatal stroke (RR: 1.76; 95% CI: 1.07 to 2.91), hypotension (RR: 1.47; 95% CI: 1.34 to 1.60), and bradycardia (RR: 2.61; 95% CI: 2.18 to 3.12). These findings were qualitatively unchanged after the DECREASE and POISE-1 trials were excluded. Effects on mortality rate differed significantly between the DECREASE trials and other trials. Beta blockers were associated with a trend toward reduced all-cause mortality rate in the DECREASE trials (RR: 0.42; 95% CI: 0.15 to 1.22) but with increased all-cause mortality rate in other trials (RR: 1.30; 95% CI: 1.03 to 1.64). Beta blockers reduced cardiovascular mortality rate in the DECREASE trials (RR: 0.17; 95% CI: 0.05 to 0.64) but were associated with trends toward increased cardiovascular mortality rate in other trials (RR: 1.25; 95% CI: 0.92 to 1.71). These differences were qualitatively unchanged after the POISE-1 trial was excluded.Conclusions-Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.

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