Preoperative care > Beta-blocker evidence table

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Randomized controlled trials with at least 100 total patients and at least one death.[1][2][3][4][5][6][7][8]
(See legend and notes at bottom on the table)
Patients Intervention Comparison Outcome Results
Mortality Stroke Beta-blocker toxicity
Rx Control Rx Control Rx Control

Decrease IV[1][9]
2009
Drug provided by Merck KGaA

1066 patients:
•estimated risk of perioperative cardiovascular death of ≥ 1%
• RCRI = 2: ~100%
• < 1% vascular surgery 		Bisoprolol
• Started a median of 34 days preop
• Minimum allowed HR*: >50 bpm 		Open label Mortality at 30 days 1.9% 3.0% 0.8% 0.6% Heart failure, clinically significant bradycardia or hypotension:
0.6% 0.4%
POISE[2]
2008
Partially funded by AstraZeneca 		8351 patients:
• 42% vascular surgery
• RCRI = 2: uncertain 		Metoprolol succinate
• Started day of surgery
• Minimum allowed HR*: > 50 bpm 		Placebo Mortality at two weeks Overall 1% 0.5% Clinically significant hypotension:
3.1% 2.3% 15% 9.7%
Vascular pts
Significant benefit on composite events. Mortality by surgery type not reported.
BBSA[3]
2007
Partially funded by industry. 		224 patients:
• 1% vascular surgery
• RCRI = 2: uncertain 		Bisoprolol
• Started day of surgery
Minimum allowed HR*: > 50bpm 		Placebo Mortality at one year 0.9 0.9 1.8% 0% Hypotension:
0% 2.7%
DIPOM[4]
2006
Partially funded by AstraZeneca 		921 patients:
• 7% vascular surgery
• RCRI > 2: uncertain
• All had diabetes 		Metoprolol succinate
• Started 0-1 days preop
• Minimum allowed HR*: >55 bpm 		Placebo Mortality at a median of 18 months 16% 16% 0.4% 0% Hypotension reported as an ADR:
0.4% 0.2%
MaVS[5]
2006
No industry funding. 		496 patients:
• 100% vascular surgery
• RCRI = 2: 40%
 Metoprolol
• Start: day of surgery
• Minimum allowed HR*: > 50 bpm while awake;
>45 bpm while asleep. 		Placebo Hospital mortality 0% 1.6% 2.0% 1.6% Intraoperative hypotension treated:
46% 34%
POBBLE[6]
2005
No industry funding. 		103 patients:
• 100% vascular surgery
• RCRI > 2: uncertain
 Metoprolol
• Start with test dose one day preop
• Minimum allowed HR*: > 50 bpm 		Placebo (anesthesiologists were not blinded) Mortality at 30 days 3% 1% 2% 0% Intraoperative inotropes given:
92% 64%
Decrease[7]
1999
Uncertain funding. 		112 patients:
• 100% vascular surgery
• RCRI = 2: uncertain, at least 67%
• Abnl stress echo: 100% 		Bisoprolol
• Started a median of 37 days preop
• Minimum allowed HR*: > 50 bpm 		Open label Mortality at 30 days 3.4 17.0 Not reported Discontinuation of study drug due to ADRs:
0% 0%
Mangano/ MSPI[8]
1996
No industry funding. 		200 patients:
• 41% vascular surgery
• RCRI > 2: uncertain
 Atenolol
• Minimum allowed HR*: > 55 bpm 		Placebo Hospital mortality 4% 2% 4%[10] 1%[10] Intraoperative inotropes given:[10]
13% 13%

* Minimum allowed HR. The lowest heart rate allowed before beta-blockers were withheld.
Notes:

  1. Color indicates statistically significant differences with green indicating benefit and red indicating harm.
  2. BBSA noted more drug toxicity among patients with abnormal beta1-adrenergic receptor genetic polymorphisms.[3]
  3. Mavs had trend toward most benefit in RCRI = 3.[5]

References

  1. ↑ 1.0 1.1 Dunkelgrun M, Boersma E, Schouten O, et al. (June 2009). Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: a randomized controlled trial (DECREASE-IV). Ann. Surg. 249 (6): 921–6. DOI:10.1097/SLA.0b013e3181a77d00. PMID 19474688.
  2. ↑ 2.0 2.1 Devereaux PJ, Yang H, Yusuf S, et al. (May 2008). Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 371 (9627): 1839–47. DOI:10.1016/S0140-6736(08)60601-7. PMID 18479744.
  3. ↑ 3.0 3.1 3.2 Zaugg M, Bestmann L, Wacker J, et al. (July 2007). Adrenergic receptor genotype but not perioperative bisoprolol therapy may determine cardiovascular outcome in at-risk patients undergoing surgery with spinal block: the Swiss Beta Blocker in Spinal Anesthesia (BBSA) study: a double-blinded, placebo-controlled, multicenter trial with 1-year follow-up. Anesthesiology 107 (1): 33–44. DOI:10.1097/01.anes.0000267530.62344.a4. PMID 17585213.
  4. ↑ 4.0 4.1 Juul AB, Wetterslev J, Gluud C, et al. (June 2006). Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ 332 (7556): 1482. DOI:10.1136/bmj.332.7556.1482. PMID 16793810. PMC 1482337.
  5. ↑ 5.0 5.1 5.2 Yang H, Raymer K, Butler R, Parlow J, Roberts R (November 2006). The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am. Heart J. 152 (5): 983–90. DOI:10.1016/j.ahj.2006.07.024. PMID 17070177.
  6. ↑ 6.0 6.1 Brady AR, Gibbs JS, Greenhalgh RM, Powell JT, Sydes MR (April 2005). Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. J. Vasc. Surg. 41 (4): 602–9. DOI:10.1016/j.jvs.2005.01.048. PMID 15874923.
  7. ↑ 7.0 7.1 Poldermans D, Boersma E, Bax JJ, et al. (December 1999). The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N. Engl. J. Med. 341 (24): 1789–94. PMID 10588963.
  8. ↑ 8.0 8.1 Mangano DT, Layug EL, Wallace A, Tateo I (December 1996). Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N. Engl. J. Med. 335 (23): 1713–20. PMID 8929262.
  9. ↑ Schouten O et al. Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery: rationale and design of the DECREASE-IV study. Am Heart J. 2004 Dec;148(6):1047-52. DOI:10.1016/j.ahj.2004.05.046 PMID 15632892
  10. ↑ 10.0 10.1 10.2 Wallace A, Layug B, Tateo I, et al. (January 1998). Prophylactic atenolol reduces postoperative myocardial ischemia. McSPI Research Group. Anesthesiology 88 (1): 7–17. PMID 9447850.
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