Clinical Evidence, Practice Guidelines, and β-Blocker Utilization Before Major Noncardiac Surgery

Wijeysundera, Duminda N.; Mamdani, Muhammad; Laupacis, Andreas; Fleisher, Lee A.; Beattie, W. Scott; Kolstad, Jonathan T.; Neuman, Mark D.

doi:10.1161/circoutcomes.112.965632

Cited by 19 publications

(14 citation statements)

References 46 publications

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“…2,6 Similar findings have been recently reported by Canadian investigators during this timeframe. 5 We were unable to demonstrate significant differences between our post hoc definitions of long-term use or acute institution of ␤-blockade. Limited evidence suggests that long-term use of ␤-blockade is associated with lower rates of adverse outcome than institution within 1 week of or immediately after surgery.…”

Section: Discussionmentioning

confidence: 65%

Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery

London¹,

Hur²,

Schwartz³

et al. 2013

JAMA

192

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ImportanceThe effectiveness of perioperative ␤-blockade in patients undergoing noncardiac surgery remains controversial.Objective To determine the associations of early perioperative exposure to ␤-blockers with 30-day postoperative outcome in patients undergoing noncardiac surgery. Design, Setting, and PatientsA retrospective cohort analysis evaluating exposure to ␤-blockers on the day of or following major noncardiac surgery among a populationbased sample of 136 745 patients who were 1:1 matched on propensity scores (37 805 matched pairs) treated at 104 VA medical centers from January 2005 through August 2010.Main Outcomes and Measures All cause 30-day mortality and cardiac morbidity (cardiac arrest or Q-wave myocardial infarction). ResultsOverall 55 138 patients (40.3%) were exposed to ␤-blockers. Exposure was higher in the 66.7% of 13 863 patients undergoing vascular surgery (95% CI, 65.9%-67.5%) than in the 37.4% of 122 882 patients undergoing nonvascular surgery (95% CI, 37.1%-37.6%; PϽ.001). Exposure increased as Revised Cardiac Risk Index factors increased, with 25.3% (95% CI, 24.9%-25.6%) of those with no risk vs 71.3% (95% CI, 69.5%-73.2%) of those with 4 risk factors or more exposed to ␤-blockers (PϽ.001). Death occurred among 1.1% (95% CI, 1.1%-1.2%) and cardiac morbidity occurred among 0.9% (95% CI, 0.8%-0.9%) of patients. In the propensity matched cohort, exposure was associated with lower mortality (relative risk [RR], 0.73; 95% CI, 0.65-0.83; PϽ.001; number need to treat [NNT], 241; 95% CI, 173-397). When stratified by cumulative numbers of Revised Cardiac Risk Index factors, ␤-blocker exposure was associated with significantly lower mortality among patients with 2 factors (RR, 0.63 [95% CI, 0.50-0.80]; PϽ.001; NNT, 105 [95% CI, 69-212]), 3 factors (RR, 0.54 [95% CI, 0.39-0.73]; PϽ.001; NNT, 41 [95% CI, 28-80]), or 4 factors or more (RR, 0.40 [95% CI, 0.25-0.73]; PϽ.001; NNT, 18 [95% CI,). This association was limited to patients undergoing nonvascular surgery. ␤-Blocker exposure was also associated with a lower rate of nonfatal Q-wave infarction or cardiac arrest (RR, 0.67 [95% CI, 0.57-0.79]; PϽ.001; NNT, 339 [95% CI,), again limited to patients undergoing nonvascular surgery.Conclusions and Relevance Among propensity-matched patients undergoing noncardiac, nonvascular surgery, perioperative ␤-blocker exposure was associated with lower rates of 30-day all-cause mortality in patients with 2 or more Revised Cardiac Risk Index factors. Our findings support use of a cumulative number of Revised Cardiac Risk Index predictors in decision making regarding institution and continuation of perioperative ␤-blockade. A multicenter randomized trial involving patients at a low to intermediate risk by these factors would be of interest to validate these observational findings.

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Section: Discussionmentioning

confidence: 65%

Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery

London¹,

Hur²,

Schwartz³

et al. 2013

JAMA

192

View full text Add to dashboard Cite

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“…A recent AHA systematic review [23] supporting the updated recommendations on perioperative beta blockade identified 17 studies, all but two initiated a beta blocker 1 day or less before surgery. The pooled data of studies starting beta blockers 1 day or less before surgery showed a reduction in nonfatal myocardial infarction, but increased rates of stroke, death, hypotension, and bradycardia.…”

Section: Beta Blockersmentioning

confidence: 99%

New therapy in cardioprotection

Chow

Liu²,

Irwin³

2015

Current Opinion in Anaesthesiology

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“…Hospitals and clinical departments undertook strategies to promote local adherence to β-blocker guidelines 38 39. In clinical practice, use of preoperative β-blockade increased rapidly between 1999 and 2005,40 reflecting one observer's sentiment that ‘the paradigm is shifting from predicting which patient is at high risk…to minimizing the likelihood of such an event with specific perioperative pharmacologic therapy’ 41…”

Section: Construction Of An Evidence-based Practice: the Emergence Ofmentioning

confidence: 99%

Learning from mistakes in clinical practice guidelines: the case of perioperative β-blockade

2014

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For more than two decades, the role of beta-blockers in preventing cardiac complications after major surgery has been the subject of contentious scientific and policy debate. Based on two small but highly publicized randomized trials published in 1996 and 1999, prominent U.S. organizations embraced preoperative beta-blocker initiation as a “best practice” and an opportunity for widespread safety improvement. Yet only a few years later, expert recommendations regarding preoperative beta-blockers were revised and downgraded when subsequent research failed confirm promising early findings and called attention to potential harms associated with beta-blocker overuse. In this paper, we trace the history of preoperative beta-blocker recommendations as a case study in lessons to be learned from reversals of guideline recommendations based initially on evidence drawn from randomized, controlled trials. Ultimately, we find that the policy significance that stakeholders ascribed to early beta-blocker studies combined with the prestige that experts assigned to the randomized controlled trial as a form of evidence to short-circuit discourse on the risks of preoperative beta-blocker initiation and led it to be elevated prematurely as a best practice. As such, the story of preoperative beta-blockers illustrates threats to objectivity in guidelines that can emerge from policy imperatives that lend primacy to the rapid translation of research into practice and from perspectives that unduly emphasize the strengths of randomized trials.

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Clinical Evidence, Practice Guidelines, and β-Blocker Utilization Before Major Noncardiac Surgery

Abstract: Background-Largely on the basis of 2 randomized trials published in the 1990s, β-blockers were initially promoted as an evidence-based intervention for preventing cardiac complications of noncardiac surgery.

Cited by 19 publications

References 46 publications

Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery

Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery

New therapy in cardioprotection

Learning from mistakes in clinical practice guidelines: the case of perioperative β-blockade

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