BJA Advance Access published online on November 19, 2007
British Journal of Anaesthesia, doi:10.1093/bja/aem331
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Meta-analysis of the effect of heart rate achieved by perioperative beta-adrenergic blockade on cardiovascular outcomes
1 Department of Anaesthetics, Nelson R. Mandela School of Medicine, Private Bag 7, Congella, Kwazulu-Natal 4013, South Africa
2 Nuffield Department of Anaesthetics, University of Oxford, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK
* Corresponding author: Department of Anaesthetics, Nelson R. Mandela School of Medicine, Private Bag 7, Congella, Kwazulu-Natal 4013, South Africa. E-mail: bruce.biccard{at}nda.ox.ac.uk
Background: Acute perioperative beta-adrenergic blockade may be cardioprotective in the high-risk cardiac patient for major non-cardiac surgery. We have investigated the association between the heart rate achieved with perioperative beta-blockade and the incidence of perioperative cardiac complications.
Methods: We identified eight randomized studies (1931 patients) reporting acute perioperative beta-blockade and major perioperative cardiovascular outcomes after non-cardiac surgery. The mean heart rates within the first 72 h after operation were analysed. A meta-analysis of means was conducted using a random effects model. A bivariate correlation analysis was conducted using Spearman’s correlation coefficient to assess for an association between the mean postoperative heart rate and the 30 day cardiac outcomes.
Results: Acute perioperative beta-blockade did not significantly reduce 30 day cardiac death [odds ratio (OR) 0.35, 95% confidence interval (CI) 0.08–1.52] or non-fatal myocardial infarction (OR 0.90, 95% CI 0.52–1.56) in the studies with adequate methodology. The mean (95% CI) heart rate was 73 (71–74) beats min–1 in the beta-blockade group, which was significantly lower than the placebo group (mean heart rate 82, P=0.0001). There was no correlation between heart rate and 30 day cardiac complications (P=0.848). The reduction in heart rate was associated with increased drug-associated adverse events (OR 2.53, 95% CI 2.05–3.13, P<0.0001). A major limitation of this analysis may be that postoperative heart rate was not a primary outcome in any of the studies identified and the mean postoperative heart rate achieved may be too high to realize optimal cardioprotection.
Conclusion: This meta-analysis cannot confirm that heart rate control with beta-adrenergic blockade is cardioprotective. A randomized controlled trial examining the effect of tight perioperative heart rate control with beta-adrenergic blockade on clinically important outcomes and adverse events is warranted.
Keywords: complications, morbidity; complications, myocardial infarction; heart, heart rate; surgery, non-cardiac; sympathetic nervous system, adrenergic block
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