Extended-release metoprolol succinate reduced the 30-day composite of cardiovascular death, nonfatal MI, or nonfatal cardiac arrest by 16% (HR 0.84) compared to placebo in patients undergoing noncardiac surgery, but significantly increased total mortality and stroke.
Does perioperative beta-blockade improve cardiovascular outcomes and mortality in patients undergoing noncardiac surgery?
Perioperative beta-blockade reduces nonfatal myocardial infarction but may significantly increase the risk of stroke and mortality if initiated acutely at high doses before noncardiac surgery, challenging routine prophylactic use.
Hazard Ratio: 0.84 (95% CI 0.7–0.99)
Absolute Event Rate: 5.8% vs 6.9%
p-value: p=0.0399
Guidelines on perioperative management of patients undergoing noncardiac surgery recommend the use of prophylactic perioperative beta-blockers in high-risk patients who are not already taking them, and their continuance in patients on chronic beta-blockade prior to surgery. These recommendations were challenged recently by results of the Perioperative Ischemic Evaluation (POISE), a large randomized trial of extended-release metoprolol succinate started immediately before noncardiac surgery in patients at high risk for atherosclerotic disease. While metoprolol significantly reduced myocardial infarctions relative to placebo in POISE, it also was associated with significant excesses of both stroke and mortality. The merits and limitations of POISE and its applicability in light of other trials of perioperative beta-blockade are debated here by two experts in the field-Dr. Don Poldermans and Dr. P. J. Devereaux (co-principal investigator of POISE).
Poldermans et al. (2009) conducted a review in Noncardiac surgery in patients with or at risk of atherosclerotic disease (n=8,351). Extended-release metoprolol succinate vs. Placebo was evaluated on 30-day composite of cardiovascular death, nonfatal MI, or nonfatal cardiac arrest (HR 0.84, 95% CI 0.70-0.99, p=0.0399). Extended-release metoprolol succinate reduced the 30-day composite of cardiovascular death, nonfatal MI, or nonfatal cardiac arrest by 16% (HR 0.84) compared to placebo in patients undergoing noncardiac surgery, but significantly increased total mortality and stroke.