Beta Blockers In Non-cardiac Surgery Research Articles

Quantity Over Quality: How the Rise in Quality Measures is Not Producing Quality Results.

Over the past decade, quality measures (QMs) have been implemented nationally in order to establish standards aimed at improving the quality of care. With the expansion of their role in the Affordable Care Act and pay-for-performance, QMs have had an increasingly significant impact on clinical practice. However, adverse patient outcomes have resulted from adherence to some previously promulgated performance measures. Several of these QMs with unintended consequences, including the initiation of perioperative beta-blockers in noncardiac surgery and intensive insulin therapy for critically ill patients, were instituted as QMs years before large randomized trials ultimately refuted their use. The future of quality care should emphasize the importance of evidence-based, peer-reviewed measures.

Perioperative beta-blockers in noncardiac surgery: the evidence continues to evolve.

The effectiveness and safety of giving beta-blockers to patients undergoing noncardiac surgery remain controversial. The use of these drugs in this clinical scenario increased after the publication of two positive trials in the late 1990s and was encouraged by national organizations and clinical guidelines. However, when several subsequent studies failed to show a benefit, recommendations became more limited and use decreased. This paper reviews recent evidence for and against the perioperative use of beta-blockers.

THE ASSESSMENT AND REDUCTION OF CARDIAC EVENTS RISK IN NONCARDIAC OPERATIONS: IS THERE A NEED FOR REVIEW OF RECOMMENDATIONS?

One of the pressing problems of modern cardiology is the cardiac complications risk evaluation and correction in noncardiac surgery. Recent international guidelines on this issue have focused on the pharmacological prevention of complications while reducing the preoperative examination and preventive revascularization. The reason for this experts position has been a series of studies DECREASE, performed in the Erasmus Medical Center (The Netherlands) under the supervision of Professor D. Poldermans. However, this summer the results of these studies have found no scientific value because of the significant irregularities in their conduct. It makes to have a new look at the problem of perioperative medicine, to rethink the available scientific evidence. In this review we discussed in detail the use of beta-blockers in noncardiac surgery in view of new circumstances.

Benefits and risks associated with β-blocker prophylaxis in noncardiac surgery

The benefits and risks associated with use of beta-blocker prophylaxis in noncardiac surgery (NCS) are described. Perioperative beta-blockade is recommended by the American College of Cardiology and the American Heart Association for use in patients already on beta-blockers or in high-risk patients undergoing NCS to reduce myocardial ischemia and myocardial infarction (MI); however, the recommendations are not as clear for patients undergoing intermediate- or low-risk NCS. Numerous trials have evaluated the effect of perioperative beta-blockers on MI, stroke, bradycardia, hypotension, overall mortality, and cardiovascular mortality in patients undergoing NCS. Several trials suggest that dosing, patient population, type of NCS, genetic polymorphisms, and type of anesthesia may be important in determining the benefits and risks of perioperative beta-blockade in these patients. In the meta-analyses evaluating beta-blockers in NCS, the balance of benefits to harms associated with aggressive perioperative beta-blocker therapy was not favorable. However, the largest, most recent trial drove the meta-analyses results and has some methodological caveats and limitations that must be considered. Recent meta-analyses have found that the use of beta-blockers reduces the rate of MI but increases the frequency of stroke, and these MIs and strokes can occur with differing severities. Perioperative use of beta-blockers in NCS can protect against postoperative MI but increases the risk of stroke, severe hypotension, and severe bradycardia. Although less common, the strokes are severe, and the troubling trend toward increasing cardiovascular and total mortality precludes the recommendation for their use in patients not previously treated with beta-blockers.

Perioperative β blockers in patients having non-cardiac surgery: a meta-analysis

American College of Cardiology and American Heart Association (ACC/AHA) guidelines on perioperative assessment recommend perioperative beta blockers for non-cardiac surgery, although results of some clinical trials seem not to support this recommendation. We aimed to critically review the evidence to assess the use of perioperative beta blockers in patients having non-cardiac surgery. We searched Pubmed and Embase for randomised controlled trials investigating the use of beta blockers in non-cardiac surgery. We extracted data for 30-day all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction, non-fatal stroke, heart failure, and myocardial ischaemia, safety outcomes of perioperative bradycardia, hypotension, and bronchospasm. 33 trials included 12 306 patients. beta blockers were not associated with any significant reduction in the risk of all-cause mortality, cardiovascular mortality, or heart failure, but were associated with a decrease (odds ratio [OR] 0.65, 95% CI 0.54-0.79) in non-fatal myocardial infarction (number needed to treat [NNT] 63) and decrease (OR 0.36, 0.26-0.50) in myocardial ischaemia (NNT 16) at the expense of an increase (OR 2.01, 1.27-3.68) in non-fatal strokes (number needed to harm [NNH] 293). The beneficial effects were driven mainly by trials with high risk of bias. For the safety outcomes, beta blockers were associated with a high risk of perioperative bradycardia requiring treatment (NNH 22), and perioperative hypotension requiring treatment (NNH 17). We recorded no increased risk of bronchospasm. Evidence does not support the use of beta-blocker therapy for the prevention of perioperative clinical outcomes in patients having non-cardiac surgery. The ACC/AHA guidelines committee should soften their advocacy for this intervention until conclusive evidence is available.

Beta-blockers in noncardiac surgery: do they really work?

Beta-blockers in noncardiac surgery: do they really work?