The Pharmaceutical Journal
Vol 280 No 7502 p590
17 May 2008

This article
Reprint   Photocopy

  Acrobat Reader

News summary

Reconsider advice on beta-blocker use in surgery

Peri-operative beta-blockers in non-cardiac surgery reduce the risk of non-fatal heart attack but increase the risk of death and stroke, according to research published online in The Lancet (13 May 2008). The authors suggest that guidelines advocating the use of peri-operative beta-blockers should be reconsidered.

Researchers in Canada conducted a trial to assess the effects of peri-operative beta-blockers in non-cardiac surgery after previous trials showed conflicting results.

They recruited 8,351 patients with or at risk of atherosclerotic disease in 190 hospitals across 23 countries. Patients were randomised to receive extended-release metoprolol or placebo, which was started two to four hours before surgery and continued for 30 days. The primary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction and non-fatal cardiac arrest.

Fewer patients in the metoprolol group than in the placebo group reached the primary endpoint (P=0.0399), as a result of fewer heart attacks in the metoprolol group (hazard ratio 0.73, 95 per cent confidence interval 0.60–0.89; P=0.0017).

However, more people in the metoprolol group had a stroke (2.17, CI 1.26–3.74; P=0.0053) and more people died (1.33, CI 1.03–1.74; P=0.0317) than in the placebo group.

The results suggest that for every 1,000 patients undergoing non-cardiac surgery, extended-release metoprolol would prevent 15 heart attacks, three cardiac revascularisations and seven patients from developing atrial fibrillation.

However, it would result in an excess of eight deaths, five strokes, 53 episodes of hypotension and 42 of bradycardia, say the researchers.

In an accompanying editorial (ibid), Lee Fleisher, University of Pennsylvania, Philadelphia, and Don Poldermans, Erasmus Medical Centre, Rotterdam, agree that high-dose beta-blockers are associated with greater risk than benefit but say that they believe low-dose long-acting agents titrated to effect at least seven days in advance (as used in the DECREASE trials) are associated with overall benefit.