Perioperative beta blockers to give or not give.

Recent European in 2009 and American guidelines advise to use  beta blockers in patients undergoing non cardiac surgery for preventing vascular events.  These guidelines were predominantly based on DECREASE trials. 2 years back fabrication of DECREASE trials data was detected by Erasmus MC Follow-up Investigation Committee. Because Don Poldermans was chairperson of European guidelines and also principal investigator of DECREASE trial, credibility of guidelines is being questioned since then.

ACC and ESC guidelines for perioperative betablocker

Recently article published in European heart journal by Cole and Francis urged guidelines makers to retract the guidelines, but instead article of Cole and Francis was retracted. According Cole and Francis estimates at least 800,000 deaths have occurred due this guidelines in UK (probably this is over estimate or may not correct).  Last year a meta-analysis was done Sonia Bouri, Matthew James Shun-Shin, Graham D Cole, Jamil Mayet, Darrel P Francis showed beta-blockers increase mortality in Perioperative period by 27%, in their meta-analysis they have excluded DECREASE trials from main analysis. When DECREASE trials were excluded from the analysis, beta-blockers increased mortality. Kindly see the forest plot below. In that forest plots POISE trial cause largest impact and analysis, so essentially this meta-analysis just an estimate of POISE trial. POISE trial doseging of Metoprolol extended release was more than 100mg and in some cases it reached 400mg per day this increase was done very acutely. In real world practice we almost never use Metoprolol XL/SR more than 100mg. so this POISE trial is for from practicing reality, although Sonia Bouri substantiates this is not high dose by saying decrease bioavailability of XL/SR preparation.

On one side guidelines based on DECREASE trail say beta-blocker are to be used but mata-analysis by Sonia Bouri reflecting impractical POISE trail say beta blocker increase mortality,  an article by Prashant Vaishnava, MD has nicely said “Perioperative Beta-Blockade: Between a Rock and a Hard Place”. A retrospective study by London et al. showed benefit of beta blockers  on mortality in Perioperativeperiod. So I think guidelines should not be retracted based on single meta-analysis (recently FDA rejected Naproxen cardiac safety saying similarly). More often guidelines are formed by many panelists and just one man; they are all expert in the field.

Sonia bouri et al meta-analysis
Any way guidelines are due for update beginning this year 2014 we will wait and watch.

Because Perioperative beta-blockers do not have robust data either for or against, one should not with hold beta blockers in patient who is already on it from long time. If beta blockers are to be started before surgery, then start it well in advance at least 30 days to 7 days before. Do not use beta blockers just purpose of decreasing events in patient where there is no indication otherwise, keeping in mind beta blockers for treating hypertension now is in fourth place.

Author: Dr Umesh Bilagi

MBBS, MD, DM (cardiology). I am Interventional cardiologist. Blogging is my passion. Associate professor of cardiology KIMS Hubli. Director and consultant at Tatwadarsha Hospital Hubli. Owner of Jeevan Jyoti Hospital Hubli. Mobile +91 9343403620.

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