Perioperative β blockade: guidelines do not reflect the problems with the evidence from the DECREASE trialsBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5210 (Published 29 August 2014) Cite this as: BMJ 2014;349:g5210
All rapid responses
We read the recent article “Perioperative β blockade: guidelines do not reflect the problems with the evidence from the DECREASE trials” (1) with great interest.
As GDC quite rightly states in the postscript, we tend to perpetuate our learning to our peers. The use of evidence published in the peer reviewed arena makes us confident in our assertions.
With the publication of the reviews looking at short to medium term beta-blockade, it was clear to see that the conclusions drawn from the DECREASE trials were in strong contrast to the less convincing advantages identified by trials such as POBBLE and DiPOM (2,3,4). In fact we commented on it in response to a BMJ article published in 2011 looking at optimisation of peri-operative risk (5).
Vascular surgeons are treating an increasingly ageing patient demographic, with a significant cardiac history. Although we hope the majority have been medically optimised by the time they reach us (as the authors pointed out, the use of beta-blockade in the cardiology setting is based on different evidence with a much less controversial study base) this is not always the case. Therefore, making use of published guidelines in our practice is a natural fall back.
As busy clinicians we all dedicate our spare time to ensuring we are as up-to-date in our practice as possible, for the protection of our patients and to perpetuate sound clinical practice to our junior team. However, the lag in guideline review following publication of updated data or analysis is a major cause for concern; it can result in us questioning our use of published guidelines as a trusted resource.
Now we are left to questions ourselves again. Do assertions based on what we assume to be sound evidence make us dangerous? Should we still use them to defend our medical decisions?
RA Benson, Vascular Research Fellow, St George’s Healthcare NHS Trust
AD Pherwani, Consultant Vascular Surgeon, University Hospital of North Staffordshire
1. Perioperative β blockade: guidelines do not reflect the problems with the evidence from the DECREASE trials. BMJ 2014;349:g5210
2. Brady AR. Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. J Vasc Surg. 2005 Apr;41(4):602-9.
3. Juul AB, Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ. 2006 Jun 24;332(7556):1482.
4. Meta-analysis of secure randomised controlled trials of β-blockade to prevent perioperative death in non-cardiac surgery. Bouri S, Shun-Shin, MS, Cole GD, Mayet J, Francis DP. Heart 2014;100:456-464.
5. http://www.bmj.com/rapid-response/2011/11/03/quick-reply-clinical-review.... Benson RA, Pherwani AD.
Competing interests: No competing interests
Re: Perioperative β blockade: guidelines do not reflect the problems with the evidence from the DECREASE trials
We were very pleased to read Professor Francis and Dr Cole’s Analysis article about perioperative beta-blockade, which is long overdue (1). Although we have repeatedly pointed out the inherent weaknesses in the Mangano and Polderman’s (DECREASE) studies in this journal since 2005 the European Society of Cardiologists failed to modify their guidelines appropriately even after the Perioperative Ischaemic Evaluation or POISE trial reported (2-6).
One calculated consequence of the recommended use of perioperative beta blockade as a Class I treatment (evidence and/or general agreement that a given treatment or procedure is beneficial, useful and effective) is a 27% increase in mortality, in patients starting beta blockers in the perioperative period to reduce the risk of mortality (6,7). Applying this calculation to the NHS provides an estimate of 10,000 avoidable deaths annually in the UK alone (4,7). In our 2013 Editorial in this journal we addressed this horrifying possibility by asserting “If true this serious allegation must be investigated and guidelines corrected immediately. If it has no basis in fact, the allegation must be retracted”. We were pleased to see that the European Society of Cardiology partially corrected their erroneous 2009 recommendations following this advice. However the Joint Task Force still included the widely discredited Mangano study, even though its major flaw (failure to analyse mortality on an intention to treat basis) was highlighted in the article (8). The Joint Task Force also used meta-analyses that included the thoroughly discredited DECREASE group of studies (8-10).
The BMJ Analysis article confirms that there is now even less evidence to support the Class IIb treatment recommendation (usefulness/efficacy is less well established) of the European Society of Cardiology and we would again assert that the European Society Guidelines must be corrected immediately, which is entirely in line with the conclusions of Francis and Cole (1,4). We would also remind the Task Force that failure to modify their current guidelines is likely to contribute to an incalculable number of unnecessary patient deaths, not only in the NHS but across Europe. As one of us has said before “no institution, particularly in healthcare, can ever afford to lose sight of its patients” (11).
1. Francis DP, Cole GD. Perioperative β blockade: guidelines do not reflect the problems with the evidence from the DECREASE trials. BMJ 2014;349:doi: 10.1136.
2. Bolsin S, Colson M. Beta-blockers for patients at risk of cardiac events during non-cardiac surgery. BMJ 2005;331:919-20.
3. Bolsin S, Colson M, Conroy M. ß-blockers and statins in non-cardiac surgery. BMJ 2007;334:1283-4.
4. Bolsin SN, Colson M, Marsiglio A. Perioperative beta-blockade. BMJ 2013;347:9.
5. Devereaux PJ, Yang H, Yusuf S et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008;371:1839-47.
6. Poldermans D, Bax JJ, Boersma E et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur Heart J 2009;30:2769-812.
7. Bouri S, Shun-Shin MJ, Cole GD et al. Meta-analysis of secure randomised controlled trials of β-blockade to prevent perioperative death in non-cardiac surgery. Heart 2013;100:456-64.
8. Joint Task Force on non-cardiac surgery. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Eur Heart J 2014:doi:10.1093/eurheartj/ehu282.
9. Mangano DT, Layug EL, Wallace A et al. Effect of Atenolol on Mortality and Cardiovascular Morbidity after Noncardiac Surgery. N Engl J Med 1996;335:1713-21.
10. Leung J. Diabetes and not lack of treatment with atenolol predicts decreased survival after noncardiac surgery. Anesthesiology 1999;90:1226-7.
11. Bolsin SN. Simple lessons for the NHS from a whistleblower. The Guardian. London, 2013.
Competing interests: No competing interests