BMJ  2005;331:313-321 (6 August), doi:10.1136/bmj.38503.623646.8F (published 4 July 2005)

Paper

How strong is the evidence for the use of perioperative blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials

¹ Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada, ² Department of Surgery and Clinical Epidemiology and Biostatistics, McMaster University, ³ Department of Medicine and Population Health Research Institute, McMaster University, ⁴ Department of Anesthesia, University of Toronto, Toronto, ON, Canada, ⁵ Vancouver Coastal Health Research Institute and Department of Anesthesia, University of British Columbia, Vancouver, BC, Canada, ⁶ Departments of Anesthesiology and Perioperative Medicine, University of Western Ontario, London, ON, Canada, ⁷ Grupo de Cardiología Preventiva, Universidad Autonoma de Bucaramanga, Colombia, ⁸ Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia, ⁹ Departments of Anesthesiology and Critical Care, University of Alberta, Edmonton, AB, Canada, ¹⁰ Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA, ¹¹ Dante Pazzanese Institute of Cardiology and the Albert Einstein Hospital, São Paulo, Brazil, ¹² Nuffield Department of Anaesthetics, University of Oxford, ¹³ Department of Anesthesia, McGill University, Montreal, QC, Canada, ¹⁴ Department of Anesthesia, University of Ottawa, Ottawa, ON, Canada, ¹⁵ Department of Anaesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark

Objective To determine the effect of perioperative blocker treatment in patients having non-cardiac surgery.

Design Systematic review and meta-analysis.

Data sources Seven search strategies, including searching two bibliographic databases and hand searching seven medical journals.

Study selection and outcomes We included randomised controlled trials that evaluated blocker treatment in patients having non-cardiac surgery. Perioperative outcomes within 30 days of surgery included total mortality, cardiovascular mortality, non-fatal myocardial infarction, non-fatal cardiac arrest, non-fatal stroke, congestive heart failure, hypotension needing treatment, bradycardia needing treatment, and bronchospasm.

Results Twenty two trials that randomised a total of 2437 patients met the eligibility criteria. Perioperative blockers did not show any statistically significant beneficial effects on any of the individual outcomes and the only nominally statistically significant beneficial relative risk was 0.44 (95% confidence interval 0.20 to 0.97, 99% confidence interval 0.16 to 1.24) for the composite outcome of cardiovascular mortality, non-fatal myocardial infarction, and non-fatal cardiac arrest. Methods adapted from formal interim monitoring boundaries applied to cumulative meta-analysis showed that the evidence failed, by a considerable degree, to meet standards for forgoing additional studies. The individual safety outcomes in patients treated with perioperative blockers showed a relative risk for bradycardia needing treatment of 2.27 (95% CI 1.53 to 3.36, 99% CI 1.36 to 3.80) and a nominally statistically significant relative risk for hypotension needing treatment of 1.27 (95% CI 1.04 to 1.56, 99% CI 0.97 to 1.66).

Conclusion The evidence that perioperative blockers reduce major cardiovascular events is encouraging but too unreliable to allow definitive conclusions to be drawn.

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Rapid Responses:

Read all Rapid Responses

Negative comments are not supported by the reported results

J Robert Sneyd
bmj.com, 6 Aug 2005 [Full text]

Biased data interpretation should not be allowed

Saul G Myerson
bmj.com, 13 Aug 2005 [Full text]

Leave beta blockade to the anaesthetist and not the epidemiologists

Ewan S Jack
bmj.com, 8 Aug 2005 [Full text]

Cardiac risk stratification guides the use of beta blockers in patients undergoing non cardiac surgery

Jawad M Khan, et al.
bmj.com, 9 Aug 2005 [Full text]

Not convincing enough to change my practice

Som Kumar
bmj.com, 10 Aug 2005 [Full text]

Intra-operative hypotension is a major problem of perioperative beta-blockade

Janet T Powell, et al.
bmj.com, 17 Aug 2005 [Full text]

Perioperative blocker therapy in patients undergoing noncardiac surgery

P.J. Devereaux, et al.
bmj.com, 15 Aug 2005 [Full text]

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Mike Grocott, et al.
bmj.com, 22 Aug 2005 [Full text]

Peri-operative Beta-blockers: Much room for evidence still exists!

Ashish Aneja, et al.
bmj.com, 29 Sep 2005 [Full text]