Meta-Analysis of Secure Randomised Controlled Trials of Beta-Blockade to Prevent Perioperative Death in Non-Cardiac Surgery

Study Questions:

In a meta-analysis that excludes the discredited trials from the DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography) family of studies, what are the benefits of perioperative beta-blockade?

Methods:

This was a meta-analysis that included secure intention-to-treat randomized controlled trial data on the impact of perioperative beta-blockade on the primary outcome of all-cause mortality at 30 days or at discharge. The meta-analysis was conducted with exclusion of the DECREASE family of studies (DECREASE I was not investigated, but others have been discredited for a variety of reasons, including fictitious data).

Results:

Nine secure trials with a total of 10,529 patients were included. Compared to placebo, perioperative beta-blockade was associated with increased perioperative mortality (relative risk [RR], 1.27; 95% confidence interval [CI] ,1.01-1.60; p = 0.04). In six secure trials, perioperative beta-blockade was associated with increased risk for stroke (RR, 1.73; 95% CI, 1.00-2.99; p = 0.05), compared to placebo. In six secure trials, perioperative beta-blockade was associated with reduced risk for nonfatal myocardial infarction (RR, 0.73; 95% CI, 0.61-0.88; p = 0.001).

Conclusions:

In a meta-analysis of nine secure trials, perioperative beta-blockade was associated with increased risk of mortality and stroke, but decreased risk of nonfatal myocardial infarction.

Perspective:

This is an important study that attempts to assuage the impact of the academic misconduct that has rendered the DECREASE family of studies insecure. The authors suggest, ‘Guideline bodies should retract their recommendations based on fictitious data without further delay.’ This may be overstated. The results of this meta-analysis were dominated by the results of the POISE trial—a study that has been criticized for the intensity of perioperative beta-blockade used in the study protocol (up to 400 mg of metoprolol succinate perioperatively for some patients). One should be cautious about ascriptions of harm to beta-blockade based on a meta-analysis so heavily influenced by a trial that used an intensity of perioperative beta-blockade that is unlikely to represent routine clinical practice.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Echocardiography/Ultrasound

Keywords: Stroke, Myocardial Infarction, Echocardiography, Stress, Patient Discharge, Dobutamine, Disopyramide, Perioperative Care, Cardiology, Cardiovascular Diseases, Bisoprolol, Confidence Intervals, Metoprolol, Cardiac Surgical Procedures


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