Preoperative care/Catalogs/Beta-blocker evidence table: Difference between revisions

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| rowspan="2" |
| rowspan="2" |
Decrease IV<ref name="pmid19474688"/><br />2009
Decrease IV<ref name="pmid19474688"/><br />2009
| rowspan="2" valign="top" | 1066 patients<br /> * Vascular: &lt; 1%<br /><nowiki>*</nowiki> [[Revised Cardiac Risk Index|RCRI]] &gt; 2: 0%
| rowspan="2" valign="top" | 1066 patients<br /> * Vascular: &lt; 1%<br /><nowiki>*</nowiki> [[Revised Cardiac Risk Index|RCRI]] 2: 100%
| rowspan="2" | Bisoprolol<br /><nowiki>* Started a median of 34 days preop</nowiki><br /><nowiki>* Target HR: >50 bpm</nowiki>
| rowspan="2" | Bisoprolol<br /><nowiki>* Started a median of 34 days preop</nowiki><br /><nowiki>* Target HR: >50 bpm</nowiki>
| rowspan="2" | Open label
| rowspan="2" | Open label
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|-
|-
| rowspan="4" |POISE<ref name="pmid18479744"/><br />2008
| rowspan="4" |POISE<ref name="pmid18479744"/><br />2008
| rowspan="4" valign="top" | 8351 patients<br /> * Vascular: 42%<br /><nowiki>*</nowiki> [[Revised Cardiac Risk Index|RCRI]] &gt; 2: uncertain
| rowspan="4" valign="top" | 8351 patients<br /> * Vascular: 42%<br /><nowiki>*</nowiki> [[Revised Cardiac Risk Index|RCRI]] 2: uncertain
| rowspan="4" valign="top"| Metoprolol<br /><nowiki>* Started day of surgery</nowiki><br /><nowiki>* Target HR: &gt; 50 bpm</nowiki>
| rowspan="4" valign="top"| Metoprolol<br /><nowiki>* Started day of surgery</nowiki><br /><nowiki>* Target HR: &gt; 50 bpm</nowiki>
| rowspan="4" | Placebo
| rowspan="4" | Placebo
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|-
|-
| rowspan="2" |BBSA<ref name="pmid17585213"/><br /> 2007
| rowspan="2" |BBSA<ref name="pmid17585213"/><br /> 2007
| rowspan="2" valign="top" | 224 patients<br /><nowiki>*</nowiki> Spinal anesthesia<br /><nowiki>*</nowiki> Vascular: 1%<br /><nowiki>*</nowiki> [[Revised Cardiac Risk Index|RCRI]] > 2: 3%
| rowspan="2" valign="top" | 224 patients<br /><nowiki>*</nowiki> Spinal anesthesia<br /><nowiki>*</nowiki> Vascular: 1%<br /><nowiki>*</nowiki> [[Revised Cardiac Risk Index|RCRI]] 2: uncertain
| rowspan="2" valign="top" | Bisoprolol<br /><nowiki>* Started day of surgery</nowiki><br />Target HR: > 50bpm
| rowspan="2" valign="top" | Bisoprolol<br /><nowiki>* Started day of surgery</nowiki><br />Target HR: > 50bpm
| rowspan="2" | Placebo
| rowspan="2" | Placebo
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|-
|-
| rowspan="2" |DIPOM<ref name="pmid16793810"/><br /> 2006
| rowspan="2" |DIPOM<ref name="pmid16793810"/><br /> 2006
| rowspan="2" valign="top" | 921 patients<br /><nowiki>* All had diabetes</nowiki><br /><nowiki>* Vascular: 7%</nowiki>
| rowspan="2" valign="top" | 921 patients<br /><nowiki>*</nowiki> Vascular: 7%<br /><nowiki>*</nowiki><br/>[[Revised Cardiac Risk Index|RCRI]] &gt; 2: uncertain<br/><nowiki>*</nowiki> All had diabetes
| rowspan="2" valign="top" | Metoprolol<br /><nowiki>* Started 0-1 days preop</nowiki><br /><nowiki>* Target HR: >55 bpm</nowiki>
| rowspan="2" valign="top" | Metoprolol<br /><nowiki>* Started 0-1 days preop</nowiki><br /><nowiki>* Target HR: >55 bpm</nowiki>
| rowspan="2" | Placebo
| rowspan="2" | Placebo
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|-
|-
| rowspan="2" |MaVS<ref name="pmid17070177"/><br />2006
| rowspan="2" |MaVS<ref name="pmid17070177"/><br />2006
| rowspan="2" valign="top" | 496 patients<br /><nowiki>* Vascular: 100%</nowiki>
| rowspan="2" valign="top" | 496 patients<br /><nowiki>*</nowiki> Vascular: 100%<br /><nowiki>*</nowiki>[[Revised Cardiac Risk Index|RCRI]] ≥ 2: 40%<br/>
| rowspan="2" valign="top" | Metoprolol<br /><nowiki>*Start: day of surgery</nowiki><br /><nowiki>* Target HR: > 50 bpm while awake;</nowiki><br />>45 bpm while asleep.
| rowspan="2" valign="top" | Metoprolol<br /><nowiki>*Start: day of surgery</nowiki><br /><nowiki>* Target HR: > 50 bpm while awake;</nowiki><br />>45 bpm while asleep.
| rowspan="2" | Placebo
| rowspan="2" | Placebo
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|-
|-
| rowspan="2" | POBBLE<ref name="pmid15874923"/><br />2005
| rowspan="2" | POBBLE<ref name="pmid15874923"/><br />2005
| rowspan="2" valign="top" | 103 patients<br /><nowiki>* Vascular: 100%</nowiki>
| rowspan="2" valign="top" | 103 patients<br /><nowiki>*</nowiki> Vascular: 100%<br /><nowiki>*</nowiki>[[Revised Cardiac Risk Index|RCRI]] &gt; 2: uncertain<br/>
| rowspan="2" valign="top" | Metoprolol<br /><nowiki>* Start with test dose one day preop</nowiki><br /><nowiki>* Target HR: > 50 bpm</nowiki>
| rowspan="2" valign="top" | Metoprolol<br /><nowiki>* Start with test dose one day preop</nowiki><br /><nowiki>* Target HR: > 50 bpm</nowiki>
| rowspan="2" | Placebo (anesthesiologists were not blinded)
| rowspan="2" | Placebo (anesthesiologists were not blinded)
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|-
|-
| rowspan="2" |Decrease<ref name="pmid10588963"/><br />1999
| rowspan="2" |Decrease<ref name="pmid10588963"/><br />1999
| rowspan="2" valign="top" | 112 patients<br /><nowiki>* Vascular surgery: 100%</nowiki><br /><nowiki>* Abnl stress echo: 100%</nowiki>
| rowspan="2" valign="top" | 112 patients<br /><nowiki>*</nowiki> Vascular surgery: 100%<br /><nowiki>*</nowiki>[[Revised Cardiac Risk Index|RCRI]] ≥ 2: uncertain, at least 67%<br/><nowiki>* Abnl stress echo: 100%</nowiki>
| rowspan="2" valign="top" | Bisoprolol<br /><nowiki>* Started a median of 37 days preop</nowiki><br /><nowiki>* Target HR: > 50 bpm</nowiki>
| rowspan="2" valign="top" | Bisoprolol<br /><nowiki>* Started a median of 37 days preop</nowiki><br /><nowiki>* Target HR: > 50 bpm</nowiki>
| rowspan="2" | Open label
| rowspan="2" | Open label
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|-
|-
| rowspan="2" |Wallace/ MSPI<ref name="pmid8929262"/><br />1996
| rowspan="2" |Wallace/ MSPI<ref name="pmid8929262"/><br />1996
| rowspan="2" valign="top" | 200 patients<br /><nowiki>* Vascular: 41%</nowiki>
| rowspan="2" valign="top" | 200 patients<br /><nowiki>*</nowiki> Vascular: 41%<br /><nowiki>*</nowiki>[[Revised Cardiac Risk Index|RCRI]] &gt; 2: uncertain<br/>
| rowspan="2" valign="top" | Atenolol<br /><nowiki>* Target HR: > 55 bpm</nowiki>
| rowspan="2" valign="top" | Atenolol<br /><nowiki>* Target HR: > 55 bpm</nowiki>
| rowspan="2" | Placebo
| rowspan="2" | Placebo

Revision as of 11:48, 9 July 2009

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]
2009

1066 patients
* Vascular: < 1%
* RCRI ≥ 2: 100%
Bisoprolol
* Started a median of 34 days preop
* Target 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
8351 patients
* Vascular: 42%
* RCRI ≥ 2: uncertain
Metoprolol
* Started day of surgery
* Target 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
BBSA[3]
2007
224 patients
* Spinal anesthesia
* Vascular: 1%
* RCRI ≥ 2: uncertain
Bisoprolol
* Started day of surgery
Target HR: > 50bpm
Placebo Mortality at one year 0.9 0.9 1.8% 1.8% Hypotension:
0% 2.7%
DIPOM[4]
2006
921 patients
* Vascular: 7%
*
RCRI > 2: uncertain
* All had diabetes
Metoprolol
* Started 0-1 days preop
* Target 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
496 patients
* Vascular: 100%
*RCRI ≥ 2: 40%
Metoprolol
*Start: day of surgery
* Target HR: > 50 bpm while awake;
>45 bpm while asleep.
Placebo Hospital mortality 0% 1.6% Not reported Intraoperative hypotension treated
46% 34%
POBBLE[6]
2005
103 patients
* Vascular: 100%
*RCRI > 2: uncertain
Metoprolol
* Start with test dose one day preop
* Target HR: > 50 bpm
Placebo (anesthesiologists were not blinded) Mortality at 30 days 3% 1% 2% 0% Intraoperative inotropes given
92% 64%
Decrease[7]
1999
112 patients
* Vascular surgery: 100%
*RCRI ≥ 2: uncertain, at least 67%
* Abnl stress echo: 100%
Bisoprolol
* Started a median of 37 days preop
* Target HR: > 50 bpm
Open label Mortality at 30 days 3.4 17.0 Not reported Discontinuation of study drug due to ADRs
0% 0%
Wallace/ MSPI[8]
1996
200 patients
* Vascular: 41%
*RCRI > 2: uncertain
Atenolol
* Target HR: > 55 bpm
Placebo 4% 2% Not reported Discontinuation of study drug due to ADRs
0% 0%
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. Research Blogging.
  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. Research Blogging.
  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. Research Blogging.
  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. Research Blogging.
  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. Research Blogging.
  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. Research Blogging.
  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[e]
  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[e]