What question did this study set out to answer?

To assess the effectiveness and safety of perioperatively administered beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery.

September 26, 2019Cochrane libraryOpen Access

Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery

Q: What is the clinical evidence from this study?

Study design: Systematic Review. Population: Non-cardiac surgery (n=14967). Intervention: Perioperative beta-blockers vs. Placebo or standard care. Primary outcome: Early all-cause mortality (within 30 days) (RR 1.17, 95% CI 0.89 to 1.54).

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Key result

Perioperative beta-blockers had an uncertain effect on 30-day all-cause mortality (RR 1.17) in adults undergoing non-cardiac surgery, but reduced myocardial infarctions while increasing bradycardia and hypotension.

Why the study?

Randomized controlled trials yielded conflicting results regarding the ability of beta-blockers to influence perioperative cardiovascular morbidity and mortality, leaving routine prescription in an unselected population controversial.

Do perioperative beta-blockers reduce surgery-related mortality and morbidity in adults undergoing non-cardiac surgery?

Population

14,967 adults undergoing non-cardiac surgery across 83 RCTs

Comparison

Perioperative beta-blockers vs placebo or standard care

Design

Systematic review and meta-analysis of RCTs

Follow-up

30 days

Authors

HBHermann BlessbergerElectrophysiology SLSharon R LewisUniversity of Manchester MPMichael PritchardUniversity Hospitals of Morecambe Bay NHS Foundation Trust

Discussion

Member takes

Implication

Uncertain effects on mortality and MI in non-cardiac surgery; leaves open optimal perioperative strategy.

Key Points

To assess the effectiveness and safety of perioperatively administered beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery.
Systematic review and meta-analysis of 83 randomized controlled trials with 14,967 adults undergoing non-cardiac surgery ranging from low to high risk.
Evaluated perioperative administration of beta-blockers (such as metoprolol, propranolol, and atenolol) compared to placebo or standard care across major medical databases through June 2019.
Assessed outcomes including 30-day all-cause mortality, myocardial infarction, cerebrovascular events, and adverse hemodynamic events using GRADE certainty ratings.
Evidence for 30-day all-cause mortality was uncertain (RR 1.17, 95% CI 0.89 to 1.54; 16 studies, 11,446 participants; low certainty), and no clear difference was observed for cerebrovascular events (RR 1.65, 95% CI 0.97 to 2.81; 6 studies, 9,460 participants; low certainty).
Beta-blockers reduced the risk of myocardial infarction (RR 0.72, 95% CI 0.60 to 0.87; 12 studies, 10,520 participants; low certainty) and atrial fibrillation or flutter (RR 0.41, 95% CI 0.21 to 0.79; 9 studies, 9,080 participants; low certainty).
Beta-blockers increased the incidence of bradycardia (RR 2.49, 95% CI 1.74 to 3.56; 49 studies, 12,239 participants; low certainty) and hypotension (RR 1.40, 95% CI 1.29 to 1.51; 49 studies, 12,304 participants; moderate certainty).

Study Design

Type

Systematic Review (n=14,967)

Structured PICO

Do perioperative beta-blockers reduce surgery-related mortality and morbidity in adults undergoing non-cardiac surgery?

Population

14,967 adults undergoing non-cardiac surgery under general anaesthesia across 83 randomized controlled trials, assessed for perioperative mortality and morbidity.

Intervention

Perioperative beta-blockers (propranolol, metoprolol, esmolol, landiolol, nadolol, atenolol, labetalol, oxprenolol, or pindolol) administered before, during, or after surgery.

Comparator

Placebo or standard care.

Outcome

All-cause mortality at 30 dayshard clinical

Main Result

Relative Risk: 1.17 (95% CI 0.89–1.54)

Absolute Event Rate: 2.9% vs 2.5%

In adults undergoing non-cardiac surgery, perioperative beta-blockers reduce the incidence of myocardial infarction and atrial fibrillation but significantly increase the risk of bradycardia and hypotension, with no clear benefit on 30-day mortality.

Limitations

High risk of bias in some included studies, particularly open-label standard care control groups
Inconsistency in evidence, with one large international study showing different results from smaller studies
Imprecision for some outcomes due to few studies with few participants
Effects were sometimes altered when excluding studies with a standard care control group
High risk of bias in some studies
Open-label design in standard care control studies
Inconsistency of results across studies (e.g., one large international study showed different results)
Imprecision due to few studies/participants for some outcomes

Cite This Study

Blessberger et al. (2019) conducted a systematic review in Non-cardiac surgery (n=14,967). Perioperative beta-blockers vs. Placebo or standard care was evaluated on Early all-cause mortality (within 30 days) (RR 1.17, 95% CI 0.89 to 1.54). Perioperative beta-blockers had an uncertain effect on 30-day all-cause mortality (RR 1.17) in adults undergoing non-cardiac surgery, but reduced myocardial infarctions while increasing bradycardia and hypotension.

synapsesocial.com/papers/6a775dede539f649abf6ee30 https://doi.org/10.1002/14651858.cd013438

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Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery

Discussion

Member takes

Implication

Key Points

Study Design

Structured PICO

Main Result

Limitations

Cite This Study

Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery

Discussion

Member takes

Implication

Key Points

Study Design

Structured PICO

Main Result

Limitations

Cite This Study

Also Consider

Also Consider