Archive for February, 2014

Journal Club 5 February 2014


Meta-analysis of secure randomised controlled trials of β-blockade to prevent perioperative death in non-cardiac surgery





Current European and American
guidelines recommend the perioperative initiation of a
course of β-blockers in those at risk of cardiac events
undergoing high- or intermediate-risk surgery or vascular
surgery. The Dutch Echocardiographic Cardiac Risk
Evaluation Applying Stress Echocardiography (DECREASE)
family of trials, the bedrock of evidence for this, are no
longer secure. We therefore conducted a meta-analysis
of randomised controlled trials of β-blockade on
perioperative mortality, non-fatal myocardial infarction,
stroke and hypotension in non-cardiac surgery using the
secure data.


The randomised controlled trials of initiation
of β-blockers before non-cardiac surgery were examined.
Primary outcome was all-cause mortality at 30 days or at
discharge. The DECREASE trials were separately


Nine secure trials totalling 10 529 patients,
291 of whom died, met the criteria. Initiation of a
course of β-blockers before surgery caused a 27% risk
increase in 30-day all-cause mortality ( p=0.04). The
DECREASE family of studies substantially contradict the
meta-analysis of the secure trials on the effect of
mortality (p=0.05 for divergence). In the secure trials,
β-blockade reduced non-fatal myocardial infarction (RR
0.73, p=0.001) but increased stroke (RR 1.73, p=0.05)
and hypotension (RR 1.51, p<0.00001). These results
were dominated by one large trial.


Guideline bodies should retract their
recommendations based on fictitious data without
further delay. This should not be blocked by dispute over
allocation of blame. The well-conducted trials indicate a
statistically significant 27% increase in mortality from the
initiation of perioperative β-blockade that guidelines
currently recommend. Any remaining enthusiasts might
best channel their energy into a further randomised trial
which should be designed carefully and conducted.

Supplementary Material

The paper and supplementary material regarding the important cautionary tale in academic medicine is available here.

Categories: Journal Club