The Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
The Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
Br J Anaesth. 2018 Jul;121(1):16-25. doi: 10.1016/j.bja.2018.02.004. Epub 2018 Mar 20.
Based on landmark trials, international guidelines had for years promoted the use of beta-blockers in the setting of non-cardiac surgery. In 2011, concerns were raised regarding the integrity of some of the landmark trials, as the Dutch Erasmus Medical Center found some of them to be scientifically incorrect. Based on the remaining studies that were to be trusted, investigations showed that, in contrast to prior beliefs, the widespread use of perioperative beta-blockers might be harmful. A call for further investigations into the matter ushered in several observational studies evaluating the safety of perioperative beta-blocker therapy in specific patient subgroups. Within this review, we discuss important aspects for making these decisions, and compare the major observational studies and specific estimates of risk in subgroups of interest. We conclude that patients at high risk with heavy co-morbidities, such as heart failure, may benefit from beta-blocker therapy, whereas low-risk patients, such as patients with uncomplicated hypertension, may be at increased risk with beta-blocker therapy. We provide a critical review of current perioperative guidelines in view of the new observational data, suggesting that the recommended schematics, such as the Revised Cardiac Risk Index, for risk stratification of patients in this setting may be suboptimal. Further, we provide discussions of other aspects, including risk of sepsis, type of beta-blocker, and the potential of perioperative beta-blocker withdrawal, which may be important in guiding future studies. Summarising the current evidence, we argue that, after a precarious decade, we may just now, be back on safe ground.
基于里程碑式的临床试验，国际指南多年来一直提倡在非心脏手术中使用β受体阻滞剂。2011 年，由于荷兰伊拉斯谟医学中心发现其中一些试验在科学上存在缺陷，人们对一些里程碑式的临床试验的完整性产生了质疑。基于那些仍然值得信赖的剩余研究，调查显示，与之前的观点相反，广泛使用围手术期β受体阻滞剂可能是有害的。进一步调查这一问题的呼吁引出了几项观察性研究，评估了围手术期β受体阻滞剂治疗在特定患者亚组中的安全性。在本综述中，我们讨论了做出这些决策的重要方面，并比较了主要的观察性研究和特定亚组的风险估计。我们得出结论，患有高风险、伴有严重合并症（如心力衰竭）的患者可能从β受体阻滞剂治疗中获益，而低风险的患者（如无并发症的高血压患者）可能会因β受体阻滞剂治疗而增加风险。我们根据新的观察性数据对当前的围手术期指南进行了批判性回顾，表明推荐的方案（如修订后的心脏风险指数）可能不适合这种情况下的患者风险分层。此外，我们还讨论了其他方面，包括脓毒症风险、β受体阻滞剂的类型以及围手术期β受体阻滞剂停药的可能性，这些方面可能对指导未来的研究很重要。综合当前的证据，我们认为，在经历了一个不稳定的十年之后，我们可能刚刚回到了安全的基础上。
