Perioperative beta‐blockers to prevent death or serious even | Figure 1

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Perioperative beta‐blockers to prevent death or serious events in adults after non-cardiac surgery

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Perioperative beta‐blockers for preventing surgery‐related mortality and morbidity in adults undergoing non‐cardiac surgery

This review assessed evidence from randomized controlled trials (RCTs) on whether beta‐blockers reduce deaths or other serious events when given to people undergoing surgery other than heart surgery. The findings for heart surgery are covered in another review.

Background

Surgery increases stress in the body, which responds by releasing the hormones adrenaline and noradrenaline. Stress from surgery can lead to death or other serious events such as heart attacks, stroke, or an irregular heartbeat. For surgery that does not involve the heart, an estimated 8% of people may have injury to their heart around the time of surgery. Beta‐blockers are drugs that block the action of adrenaline and noradrenaline on the heart. Beta‐blockers can slow down the heart, and reduce blood pressure, and this may reduce the risk of serious events. However, beta‐blockers may lead to a very low heart rate or very low blood pressure which could increase the risk of death or a stroke. Prevention of early complications after surgery is important, but using beta‐blockers to prevent these complications is controversial.

Study characteristics

The evidence is current to 28 June 2019. We included 83 RCTs with 14,967 adults who were undergoing different types of surgery other than heart surgery. Eighteen studies are awaiting classification (because we did not have enough details to assess them), and three studies are ongoing. The types of beta‐blockers used in the studies were: propranolol, metoprolol, esmolol, landiolol, nadolol, atenolol, labetalol, oxprenolol, and pindolol. Studies compared these beta‐blockers with either a placebo (disguised to look like a beta‐blocker but containing no medicine) or with standard care.

Key results

Beta‐blockers may make little or no difference to the number of people who die within 30 days of surgery (16 studies, 11,446 participants; low‐certainty evidence), have a stroke (6 studies, 9460 participants; low‐certainty evidence), or experience ventricular arrhythmias (irregular heartbeat rhythms, starting in the main chambers of the heart, that are potentially life‐threatening and may need immediate medical treatment; 5 studies, 476 participants; very low‐certainty evidence). We found that beta‐blockers may reduce atrial fibrillation (an irregular heartbeat, starting in the atrial chambers of the heart, that increases the risk of stroke if untreated; 9 studies, 9080 participants; low certainty‐evidence), and the number of people who have a heart attack (12 studies, 10,520 participants; low‐certainty evidence). However, taking beta‐blockers may increase the number of people who experience a very low heart rate (49 studies, 12,239 participants; low‐certainty evidence), or very low blood pressure (49 studies, 12,304 participants; moderate‐certainty evidence), around the time of surgery.

In a few studies, we also found little or no difference in the number of people who died after 30 days, who died because of a heart problem, or had heart failure. We found no evidence of whether beta‐blockers alter the length of time in hospital.

No studies assessed whether people who were given beta‐blockers had a better quality of life after heart surgery.

Certainty of the evidence

The certainty of the evidence in this review was limited by including some studies that were at high risk of bias, and we noticed that some of our findings were different if we only included placebo‐controlled studies or studies that reported how participants were randomized. We also found one large, well‐conducted, international study that had different findings to the smaller studies. It showed a reduction in heart attacks and an increase in stroke and all‐cause mortality when beta‐blockers were used, whilst the other studies did not show a clear effect. We were also less certain of the findings for outcomes with few studies, such as for ventricular arrhythmias.

Conclusion

Although beta‐blockers may make little or no difference to the number of people who die within 30 days, have a stroke, or have ventricular arrhythmias, they may reduce atrial fibrillation and heart attacks. Taking beta‐blockers may increase the number of people with a very low heart rate or very low blood pressure around the time of surgery. Further evidence from large, placebo‐controlled trials is likely to increase the certainty of these findings, and we recommend the assessment of impact on quality of life.

Read the full Cochrane Review here

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