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1 Cardiovascular and Outcomes Research Fellow, Hartford Hospital &
University of Connecticut, Hartford, CT
2 Cardiovascular and Outcomes Research Fellow, Hartford Hospital &
University of Connecticut
3 Professor of Pharmacy, University of Connecticut; Director, Evidence-Based
Practice Center, University of Connecticut/Hartford Hospital
4 Outcomes Research Fellow, Hartford Hospital & University of
Connecticut
5 Senior Adviser for Surgical and Device Outcomes, Center for Outcomes and
Evidence, Agency for Healthcare Research and Quality, Department of Health and
Human Services, Washington, DC
6 Associate Director, Cardiology; Professor of Clinical Medicine, School of
Medicine, University of Connecticut, Hartford Hospital
7 Assistant Professor of Pharmacy Practice, School of Pharmacy, University of
Connecticut; Director, Pharmacoeconomics and Outcomes Studies Group, Hartford
Hospital
Reprints: Dr. Coleman, Hartford Hospital, 80 Seymour St., Hartford, CT 06102, fax 860/545-2277, ccolema{at}harthosp.org
BACKGROUND: Several studies have evaluated the impact on myocardial infarction (MI), stroke, and overall mortality of perioperative β-blocker use in patients undergoing noncardiac surgery (NCS). However, most studies did not have adequate sample size and statistical power and were therefore underpowered to adequately evaluate these endpoints.
OBJECTIVE: To conduct a meta-analysis to determine the balance of benefits and harms associated with perioperative β-blocker use in NCS.
METHODS: A systematic literature search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted from January 1960 through February 2009. Manual reference search was performed to identify additional relevant trials. Randomized, double-blinded, placebo-controlled trials comparing the use of β-blockers with placebo; using β-blockers perioperatively in β-blocker-naïve patients undergoing NCS; and evaluating endpoints of MI, stroke, or all-cause mortality were included.
RESULTS: Six trials (N = 10,183) met our inclusion criteria. Perioperative β-blocker use was associated with a significant reduction in patients' odds of developing MI (OR 0.74, 95% CI 0.61 to 0.89) but a significant increase in odds of developing stroke (OR 1.98, 95% CI 1.23 to 3.20) and also a nonsignificant increase in mortality (OR 1.21, 95% CI 0.98 to 1.49) versus placebo. Control-rate meta-regression determined that patients with highest baseline odds of stroke had decreased relative odds of having a stroke with a β-blocker versus placebo (β coefficient -0.97; 95% credible interval -1.04 to -0.90).
CONCLUSIONS: When perioperative β-blockers are used in NCS patients, there is a trade-off between reduction in MI and increase in stroke, with a troubling trend toward an increase in mortality. Patients with lower baseline odds of developing stroke appear to be at greater risk of β-blocker-induced stroke.
Key Words: β-blocker, ischemia, meta-analysis, noncardiac surgery
Published Online, June 16, 2009. www.theannals.com, DOI 10.1345/aph.1L706
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