Therapeutics
Review: Perioperative -blockade reduces nonfatal MI but increases mortality in noncardiac surgery Clinical impact ratings:
多多多多多多夞
Wijeysundera DN, Duncan D, Nkonde-Price C, et al. 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. J Am Coll Cardiol. 2014;64:2406-25.*
多多多多多夞夞
Questions
*Also published in Circulation. 2014;130:2246-64.
In patients having noncardiac surgery, does perioperative -blockade reduce cardiovascular (CV) morbidity and mortality? Do the results of the scientifically suspect DECREASE trials differ from those of other trials?
†Information provided by author. Source of funding: No external funding. For correspondence: Dr. D.N. Wijeysundera, Toronto General Hospital, Toronto, ON, Canada. E-mail d.wijeysundera@ utoronto.ca.
Review scope Included studies compared -blockade (excluding sotalol), initiated between 45 days before surgery and 24 hours after surgery and continuing until the earlier of day 2 after surgery or hospital discharge, with inactive control in adults ≥ 18 years of age who had noncardiac surgery. Studies had to report ≥ 1 of myocardial infarction (MI), all-cause mortality, CV mortality, or stroke.
Commentary Preoperative assessment to reduce perioperative cardiac complications is among the most common requests for cardiology consultation. Although tools to quantify preoperative risk are available (1), high-quality data on interventions to reduce risk are limited. Wijeysundera and colleagues did a systematic review and metaanalysis of 16 RCTs to quantify the risks and benefits of -blockade at various times before surgery and at various doses. 2 of the included RCTs, DECREASE-I and DECREASE-IV, are considered suspect due to potential research misconduct (2). These trials enrolled 10% of the patients in the review. When data from these trials are excluded from meta-analysis, -blockade reduces the risk for perioperative nonfatal MI but at the cost of increased rates of nonfatal stroke, hypotension, bradycardia, and death. With inclusion of the DECREASE trials, the increased risk for death is reduced to a null effect.
Review methods MEDLINE and EMBASE/Excerpta Medica (Apr 2013), Cochrane Central Register of Controlled Trials (Mar 2013), conference abstracts from relevant societies (2011 to Apr 2013), and reference lists of systematic reviews were searched for randomized controlled trials (RCTs) or cohort studies with > 100 patients. 16 RCTs (n = 12 043) and 1 cohort study (n = 348), ranging in size from 26 to 8351 patients (40% to 87% men, where reported), met the selection criteria. Risk for bias was low to intermediate for 8 trials, based on the Cochrane Collaboration Risk of Bias Tool for RCTs.
Main results
Of all included RCTs, only the DECREASE trials initiated -blockade > 1 day before surgery. Although some cohort studies address different durations of therapy (3, 4), such studies are limited by the inability to eliminate or adjust for the inevitable selection bias.
The main results for DECREASE trials and other trials are in the Table. Results for the DECREASE trials and other trials differed for all-cause (P = 0.02) and CV (P = 0.004) mortality but not for nonfatal MI (P = 0.08) or nonfatal stroke {P = 0.68}†.
Conclusions
Few data are available for drawing firm conclusions about the efficacy and safety of perioperative -blockade. Until additional data become available, it seems prudent not to initiate -blockade therapy ≤ 1 day before surgery without compelling indications to do so.
When DECREASE trials are excluded from analyses, perioperative -blockade in patients having noncardiac surgery reduces nonfatal myocardial infarction but increases all-cause mortality and nonfatal stroke. The DECREASE trials differed from other trials for all-cause and cardiovascular mortality. With the exclusion of the DECREASE trials, no RCT data are available on the initiation of -blockade > 1 day before surgery.
David L. Brown, MD Washington University School of Medicine St. Louis, Missouri, USA References
Perioperative -blockade vs inactive control in noncardiac surgery‡ Outcomes
Nonfatal MI
Trials included§
DECREASE Other
Number of Weighted event rates trials (n)
In-hospital or at 30 d
-blockade
Inactive control
RRR (95% CI)
NNT (CI)
2 (1178)
1.4%
6.1%
78% (⫺48 to 97)
Not significant
14 (10 785)
3.4%
4.8%
28% (14 to 41)
76 (52 to 151)
All-cause mortality
DECREASE
2 (1178)
1.8%
4.3%
58% (⫺22 to 85)
Not significant
CV mortality
DECREASE
2 (1178)
0.4%
2.4%
83% (36 to 95)
51 (45 to 117)
1 (1066)
0.8%
RRI (CI)
NNH (CI)
0.6%
33% (⫺70 to 493)
Not significant
Nonfatal stroke
DECREASE Other
9 (10 545)
0.7%
0.4%
86% (9 to 216)
291 (116 to 2778)
All-cause mortality
Other
14 (10 785)
3.0%
2.3%
30% (3 to 63)
143 (68 to 1425)
CV mortality
Other
12 (10 648)
1.6%
1.3%
25% (⫺8 to 71)
Not significant
1. Gupta PK, Gupta H, Sundaram A, et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation. 2011;124:381-7. 2. Chopra V, Eagle KA. Perioperative mischief: the price of academic misconduct. Am J Med. 2012;125:953-5. 3. London MJ, Hur K, Schwartz GG, Henderson WG. Association of perioperative -blockade with mortality and cardiovascular morbidity following major noncardiac surgery. JAMA. 2013;309:1704-13. 4. Andersson C, Me´rie C, Jørgensen M, et al. Association of -blocker therapy with risks of adverse cardiovascular events and deaths in patients with ischemic heart disease undergoing noncardiac surgery: a Danish nationwide cohort study. JAMA Intern Med. 2014;174:336-44.
‡CV = cardiovascular; MI = myocardial infarction; other abbreviations defined in Glossary. Weighted -blockade event rates, RRR, RRI, NNT, NNH, and CI calculated from inactive control event rates and risk ratios in article using a randomeffects model. §Analyses included DECREASE trials only or all other trials (excluding DECREASE trials).
姝 2015 American College of Physicians
JC10
ACP Journal Club
Downloaded From: https://annals.org/ by a Universite Laval Biblioteque User on 08/05/2017
Annals of Internal Medicine
19 May 2015
Review: Perioperative -blockade reduces nonfatal MI but increases mortality in noncardiac surgery Clinical impact ratings:
多多多多多多夞
Wijeysundera DN, Duncan D, Nkonde-Price C, et al. 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. J Am Coll Cardiol. 2014;64:2406-25.*
多多多多多夞夞
Questions
*Also published in Circulation. 2014;130:2246-64.
In patients having noncardiac surgery, does perioperative -blockade reduce cardiovascular (CV) morbidity and mortality? Do the results of the scientifically suspect DECREASE trials differ from those of other trials?
†Information provided by author. Source of funding: No external funding. For correspondence: Dr. D.N. Wijeysundera, Toronto General Hospital, Toronto, ON, Canada. E-mail d.wijeysundera@ utoronto.ca.
Review scope Included studies compared -blockade (excluding sotalol), initiated between 45 days before surgery and 24 hours after surgery and continuing until the earlier of day 2 after surgery or hospital discharge, with inactive control in adults ≥ 18 years of age who had noncardiac surgery. Studies had to report ≥ 1 of myocardial infarction (MI), all-cause mortality, CV mortality, or stroke.
Commentary Preoperative assessment to reduce perioperative cardiac complications is among the most common requests for cardiology consultation. Although tools to quantify preoperative risk are available (1), high-quality data on interventions to reduce risk are limited. Wijeysundera and colleagues did a systematic review and metaanalysis of 16 RCTs to quantify the risks and benefits of -blockade at various times before surgery and at various doses. 2 of the included RCTs, DECREASE-I and DECREASE-IV, are considered suspect due to potential research misconduct (2). These trials enrolled 10% of the patients in the review. When data from these trials are excluded from meta-analysis, -blockade reduces the risk for perioperative nonfatal MI but at the cost of increased rates of nonfatal stroke, hypotension, bradycardia, and death. With inclusion of the DECREASE trials, the increased risk for death is reduced to a null effect.
Review methods MEDLINE and EMBASE/Excerpta Medica (Apr 2013), Cochrane Central Register of Controlled Trials (Mar 2013), conference abstracts from relevant societies (2011 to Apr 2013), and reference lists of systematic reviews were searched for randomized controlled trials (RCTs) or cohort studies with > 100 patients. 16 RCTs (n = 12 043) and 1 cohort study (n = 348), ranging in size from 26 to 8351 patients (40% to 87% men, where reported), met the selection criteria. Risk for bias was low to intermediate for 8 trials, based on the Cochrane Collaboration Risk of Bias Tool for RCTs.
Main results
Of all included RCTs, only the DECREASE trials initiated -blockade > 1 day before surgery. Although some cohort studies address different durations of therapy (3, 4), such studies are limited by the inability to eliminate or adjust for the inevitable selection bias.
The main results for DECREASE trials and other trials are in the Table. Results for the DECREASE trials and other trials differed for all-cause (P = 0.02) and CV (P = 0.004) mortality but not for nonfatal MI (P = 0.08) or nonfatal stroke {P = 0.68}†.
Conclusions
Few data are available for drawing firm conclusions about the efficacy and safety of perioperative -blockade. Until additional data become available, it seems prudent not to initiate -blockade therapy ≤ 1 day before surgery without compelling indications to do so.
When DECREASE trials are excluded from analyses, perioperative -blockade in patients having noncardiac surgery reduces nonfatal myocardial infarction but increases all-cause mortality and nonfatal stroke. The DECREASE trials differed from other trials for all-cause and cardiovascular mortality. With the exclusion of the DECREASE trials, no RCT data are available on the initiation of -blockade > 1 day before surgery.
David L. Brown, MD Washington University School of Medicine St. Louis, Missouri, USA References
Perioperative -blockade vs inactive control in noncardiac surgery‡ Outcomes
Nonfatal MI
Trials included§
DECREASE Other
Number of Weighted event rates trials (n)
In-hospital or at 30 d
-blockade
Inactive control
RRR (95% CI)
NNT (CI)
2 (1178)
1.4%
6.1%
78% (⫺48 to 97)
Not significant
14 (10 785)
3.4%
4.8%
28% (14 to 41)
76 (52 to 151)
All-cause mortality
DECREASE
2 (1178)
1.8%
4.3%
58% (⫺22 to 85)
Not significant
CV mortality
DECREASE
2 (1178)
0.4%
2.4%
83% (36 to 95)
51 (45 to 117)
1 (1066)
0.8%
RRI (CI)
NNH (CI)
0.6%
33% (⫺70 to 493)
Not significant
Nonfatal stroke
DECREASE Other
9 (10 545)
0.7%
0.4%
86% (9 to 216)
291 (116 to 2778)
All-cause mortality
Other
14 (10 785)
3.0%
2.3%
30% (3 to 63)
143 (68 to 1425)
CV mortality
Other
12 (10 648)
1.6%
1.3%
25% (⫺8 to 71)
Not significant
1. Gupta PK, Gupta H, Sundaram A, et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation. 2011;124:381-7. 2. Chopra V, Eagle KA. Perioperative mischief: the price of academic misconduct. Am J Med. 2012;125:953-5. 3. London MJ, Hur K, Schwartz GG, Henderson WG. Association of perioperative -blockade with mortality and cardiovascular morbidity following major noncardiac surgery. JAMA. 2013;309:1704-13. 4. Andersson C, Me´rie C, Jørgensen M, et al. Association of -blocker therapy with risks of adverse cardiovascular events and deaths in patients with ischemic heart disease undergoing noncardiac surgery: a Danish nationwide cohort study. JAMA Intern Med. 2014;174:336-44.
‡CV = cardiovascular; MI = myocardial infarction; other abbreviations defined in Glossary. Weighted -blockade event rates, RRR, RRI, NNT, NNH, and CI calculated from inactive control event rates and risk ratios in article using a randomeffects model. §Analyses included DECREASE trials only or all other trials (excluding DECREASE trials).
姝 2015 American College of Physicians
JC10
ACP Journal Club
Downloaded From: https://annals.org/ by a Universite Laval Biblioteque User on 08/05/2017
Annals of Internal Medicine
19 May 2015
