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Perioperative β blockade: guidelines do not reflect the problems with the evidence from the DECREASE trials

BMJ 2014; 349 doi: (Published 29 August 2014) Cite this as: BMJ 2014;349:g5210
  1. Graham D Cole, academic clinical fellow,
  2. Darrel P Francis, professor
  1. 1International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London W2 1LA
  1. Correspondence to: G Cole g.cole{at}

The trials underpinning initiation of perioperative β blockers in patients with ischaemic heart disease having high risk surgery have largely been discredited, and the remaining evidence points to an increased risk of death. However, changes to the European guidelines have been slow. Graham Cole and Darrel Francis call for improvements to permit guideline experts to perform rapid amendments when required

Vigorous efforts have been made across Europe to promote use of protocols to reduce perioperative deaths. Since 2009 the European Society of Cardiology (ESC) guidelines have recommended the initiation of perioperative β blockade for patients with ischaemic heart disease or positive preoperative stress test results who are having high risk surgery.1 This involves giving a short course of oral β blockers from shortly before surgery until a few days or weeks after surgery and is distinct from the long term use of β blockers in heart failure, for which safety and efficacy are well proved. The aim is to reduce perioperative mortality by preventing myocardial infarction. Until 31 July 2014, the recommendation was at the strongest level, class I, which should mean that there is “evidence and/or general agreement that a given treatment or procedure is beneficial, useful, and effective.”1

The principal support for the recommendation comes from two of the DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography) family of trials, which were discredited in 2011 because of misconduct.2 Our 2013 meta-analysis of the remaining 11 credible randomised controlled trials indicates that perioperative initation of β blockade increases mortality by 27% (P=0.04, 95% confidence interval 1% to 60%).3 The ESC did not alter its guidance as soon as the DECREASE trials were discredited in 2011 or after the publication of our meta-analysis reporting an increased risk of death, and in January 2014 we published …

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