WHAT’S NEW
Avoiding β-blockers in surgery patients will prevent deaths
Bouri et al1 found that while β-blockers protect against nonfatal MIs, they increase the risk for nonfatal strokes and death. This new meta-analysis challenges the ACCF/AHA recommendations by suggesting that abandoning the use of β-blockers for preoperative patients who aren’t already taking them will prevent a substantial number of perioperative deaths. Bouri et al1 estimate that in the United Kingdom, where 47,286 deaths occur annually within 30 days of intermediate- or high-risk procedures, the number of iatrogenic deaths would drop by approximately 10,000 if β-blockers were not used.1
CAVEATS
Don’t stop β-blockers in patients who already take them
This meta-analysis did not evaluate outcomes in patients who were already taking β-blockers. These patients should continue to take them in the perioperative period, which is in line with current ACCF/AHA guidelines.
CHALLENGES TO IMPLEMENTATION
Reluctance to disregard published guidelines
Some clinicians may not be comfortable ignoring the current ACCF/AHA guidelines that make a Class IIA recommendation (it is reasonable to administer this treatment) for the use of preoperative β-blockade for patients at risk for cardiovascular events who were not previously taking a β-blocker. This updated meta-analysis excludes the discredited DECREASE trials and challenges us to act against these current guidelines while we await updated recommendations.
REFERENCES
1. Bouri S, Shun-Shin MJ, Cole GD, et al. Meta-analysis of secure randomised controlled trials of ß-blockade to prevent perioperative death in non-cardiac surgery. Heart. 2014;100:456-464.
2. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine; Society for Vascular Surgery; Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol. 2009;54:e13-e118.
3. Erasmus Medical Center Follow-up Investigation Committee. Report on the 2012 follow-up investigation of possible breaches of academic integrity (September 30, 2012). CardioBrief. Available at: http://cardiobrief.files.wordpress.com/2012/10/integrity-report-2012-10-english-translation.pdf. Accessed August 14, 2014.
4. Devereaux PJ, Yang H, Yusuf S, et al; POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;
371:1839-1847.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
Copyright © 2014. The Family Physicians Inquiries Network. All rights reserved.
Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice. 2014;63(6):E15-E16.