Use of beta-blockers in non-cardiac surgery: An open debate

The perioperative use of beta-blockers (BBs) with the aim of decreasing perioperative adverse cardiac events has been strongly supported, especially after the publication of two small trial (McSPI and DECREASE I) that showed major benefits. However, some later trials did not confirm these benefits. The POISE trial, with 8351 patients, showed reduced primary outcomes (cardiac death, non-fatal myocardial infarction, non-fatal cardiac arrest) at the expense of significant harm, increasing all-cause and sepsis-related deaths, and doubling the incidence of stroke. These results led to revised American and European guidelines. The American guideline recommended a substantial narrowing of indication for perioperative BBs, while the European guideline remained far more liberal. Since the publication of the results of POISE, meta-analyses and new studies have been published. In this review the most recent available evidence, the changes in the guidelines and the criticism on POISE results are discussed together with reasons why recent meta-analyses may not have greater certainty. This is explained by the huge numeric influence of the POISE trial and the heterogeneity in the design of the trials on perioperative BBs. Thus all the evidence available must now be taken into consideration to develop more appropriate guidelines to minimise the risks and enhance the benefits of perioperative beta-blockade.