Efficacy of Tight Heart Rate Control for Perioperative Myocardial Protection: A Systematic Review_Chinese Journal of Evidence-Based Medicine

Authors：

Mihray.Samat ,  ZHENG Hong

Department of Anesthesiology, The First Teaching Hospital of Xinjiang Medical University, Urumqi 830054, China;

Corresponding author：

ZHENG Hong, Email: xyzhenghong@yahoo.com.cn

Keywords：

β-blocker; Heart rate; Myocardial protection; Meta-analysis; Systematic review

DOI：

10.7507/1672-2531.20110097

Video：

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Objective 　To systematically review the influence of tight heart rate (HR) control on the efficacy of perioperative β-blockade, and discuss the effective measures of perioperative myocardial protection.
Methods 　We searched the PubMed, OVID, EMbase, the Cochrane Library and Chinese Biomedical Database (CBM) for randomized controlled trials on evaluating perioperative β-blockers after noncardiac surgery. The quality of the included studies was evaluated by the method recommended by the Cochrane Collaboration. Meta-analyses was conducted by using the Cochrane Collaboration’s RevMan software.
Results 　Thirteen RCTs including 11 590 patients were included. The combined results of all studies showed cardioprotective effect of β-blockers (OR=0.64, 95%CI 0.50 to 0.80, P=0.000 1), with considerable heterogeneity among the studies (I2=57%). However, grouping the trials on the basis of maximal HR showed that trials where the estimated maximal HR was 100 bpm were associated with cardioprotection (OR=0.37, 95%CI 0.26 to 0.52, P lt;0.000 01) whereas trials where the estimated maximal HR was 100 bpm did not demonstrate cardioprotection (OR=1.13, 95%CI 0.81 to 1.59, P=0.48) with no heterogeneity (I2=0%).
Conclusion 　The evidence suggests that effective control of HR is important for achieving cardioprotection and that administration of β-blockers does not reliably decrease HRs in all patients. Judicious use of combination therapy with other drugs may be necessary to achieve effective postoperative control of HR.

Citation： Mihray.Samat,ZHENG Hong. Efficacy of Tight Heart Rate Control for Perioperative Myocardial Protection: A Systematic Review. Chinese Journal of Evidence-Based Medicine, 2011, 11(5): 545-553. doi: 10.7507/1672-2531.20110097 Copy

1.	2 Bonow RO, Carabello BA, Chatterjee K, et al . ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol , 2006, 48: e1-e148.
2.	朱炜华, 万林骏. 非心脏手术围手术期β受体阻滞剂应用进展. 医学综述, 2010, 16(5): 731-734.
3.	Zuanetti G, Mantini L, Hernández-Bernal F, et al . Relevance of heart rate as a prognostic factor in patients with acute myocardial infarction: insights from the GISSI-2 study. Eur Heart J , 1998, 19 Suppl F: F19-26.
4.	吴学思. 心率在心血管疾病中的意义. 中华内科杂志, 2006, 45(7): 601-603.
5.	王春梅, 吴学思, 韩智红. 入院时心率对急性心肌梗死患者住院死亡率的影响. 中华心血管病杂志, 2008, 36(7): 594-597.
6.	Higgins JPT, Altman DG (editors). Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, greens (editors). Cochrane handbook for systematic reviews of interventions versions 5.0.1 (updated September 2008). The Cochrane Collaboration, 2008.
7.	Zaugg M, Bestmann L, Wacker J, et al . Adrenergic receptor genotype but not perioperative bisoprolol therapy may determine cardiovascular outcome in at-risk patients undergoing surgery with spinal block: the Swiss Beta Blocker in Spinal Anesthesia (BBSA) study: a double-blinded, placebo-controlled, multicenter trial with 1-year follow-up. Anesthesiology , 2007, 107(1): 33-44.
8.	van Klei WA, Bryson GL, Yang H, et al . Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology , 2009, 111(4): 717-724.
9.	Poldermans D, Boersma E, Bax JJ, et al . Bisoprolol reduces cardiac death and myocardial infarction in high-risk patients as long as 2 years after successful major vascular surgery. Eur Heart J , 2001, 22(15): 1353-1358.
10.	Raby KE, Brull SJ, Timimi F, et al . The effect of heart rate control on myocardial ischemia among high-risk patients after vascular surgery. Anesth Analg , 1999, 88(3): 477-482.
11.	Zaugg M, Tagliente T, Lucchinetti E, et al . Beneficial effects from beta-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology , 1999, 91(6): 1674-1686.
12.	Brady AR, Gibbs JS, Greenhalgh RM, et al . Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. J Vasc Surg , 2005, 41(4): 602-609.
13.	Yang H, Raymer K, Butler R, et al . The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J , 2006, 152(5): 983-990.
14.	POISE Study Group, Devereaux PJ, Yang H, et al . Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet , 2008, 371(9627): 1839-1847.
15.	赖仁纯, 许梅曦, 黄文起, 等. 美托洛尔对老年食管癌患者围手术期心脏功能的保护作用. 癌症, 2006, 25(5): 609-613.
16.	刘瑶, 黄昌林, 贺民, 等. 围手术期美托洛尔对老年非心脏手术病人血流动力学及心肌缺血的影响. 中南大学学报(医学版), 2006, 31(2): 2491.
17.	Urban MK, Markowitz SM, Gordon MA, et al . Postoperative prophylactic administration of beta-adrenergic blockers in patients at risk for myocardial ischemia. Anesth Analg , 2000; 90(6): 1257-1261.
18.	Bayliff CD, Massel DR, Inculet RI, et al . Propranolol for the prevention of postoperative arrhythmias in general thoracic surgery. Ann Thorac Surg , 1999, 67(1): 182-186.
19.	Juul AB, Wetterslev J, Gluud C, et al . Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ , 2006, 332(7556): 1482.
20.	Schouten O, Bax JJ, Dunkelgrun M, et al . Pro: Beta-blockers are indicated for patients at risk for cardiac complications undergoing noncardiac surgery. Anesth Analg , 2007, 104(1): 8-10.
21.	Sipahi I, Tuzcu EM, Wolski KE, et al . Beta-blockers and progression of coronary atherosclerosis: pooled analysis of 4 intravascular ultrasonography trials. Ann Intern Med , 2007, 147(1): 10-18.
22.	Lemaitre RN, Heckbert SR, Sotoodehnia N, et al . beta1- and beta2-adrenergic receptor gene variation, beta-blocker use and risk of myocardial infarction and stroke. Am J Hypertens , 2008, 21(3): 290-296.
23.	Fleisher LA, Beckman JA, Brown KA, ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology. J Am Coll Cardiol , 2006, 47(11): 2343-2355.
24.	Kaafarani HM, Atluri PV, Thornby J, et al . beta-Blockade in noncardiac surgery: outcome at all levels of cardiac risk. Arch Surg , 2008, 143(10):940-944.
25.	Redelmeier D, Scales D, Kopp A. Beta blockers for elective surgery in elderly patients: population based, retrospective cohort study. BMJ , 2005, 331(7522): 932.
26.	Lindenauer PK, Pekow P, Wang K, et al . Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med , 2005, 353(4): 349-361.
27.	Bangalore S, Wetterslev J, Pranesh S, et al . Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. Lancet , 2008, 372(9654): 1962-1976.
28.	Devereaux PJ, Goldman L, Yusuf S, et al . Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review. CMAJ , 2005, 173(7): 779-788.
29.	Wallace A, Layug B, Tateo I, et al . Prophylactic atenolol reduces postoperative myocardial ischemia. McSPI Research Group. Anesthesiology , 1998, 88(1): 7-17.
30.	Chopra V, Eagle KA. Perioperative beta-blockers for cardiac risk reduction: time for clarity. JAMA , 2010, 303(6): 551-552.
31.	Kadoi Y, Saito S. Possible indications of beta-blockers in the perioperative period other than prevention of cardiac ischemia. J Anesth , 2010, 24(1): 81-95.
32.	Stephens S. State of the science: beta-blockers and reduction of perioperative cardiac events. Crit Care Nurs Clin North Am , 2010, 22(2): 209-215.

1. 2 Bonow RO, Carabello BA, Chatterjee K, et al . ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol , 2006, 48: e1-e148.
2. 朱炜华, 万林骏. 非心脏手术围手术期β受体阻滞剂应用进展. 医学综述, 2010, 16(5): 731-734.
3. Zuanetti G, Mantini L, Hernández-Bernal F, et al . Relevance of heart rate as a prognostic factor in patients with acute myocardial infarction: insights from the GISSI-2 study. Eur Heart J , 1998, 19 Suppl F: F19-26.
4. 吴学思. 心率在心血管疾病中的意义. 中华内科杂志, 2006, 45(7): 601-603.
5. 王春梅, 吴学思, 韩智红. 入院时心率对急性心肌梗死患者住院死亡率的影响. 中华心血管病杂志, 2008, 36(7): 594-597.
6. Higgins JPT, Altman DG (editors). Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, greens (editors). Cochrane handbook for systematic reviews of interventions versions 5.0.1 (updated September 2008). The Cochrane Collaboration, 2008.
7. Zaugg M, Bestmann L, Wacker J, et al . Adrenergic receptor genotype but not perioperative bisoprolol therapy may determine cardiovascular outcome in at-risk patients undergoing surgery with spinal block: the Swiss Beta Blocker in Spinal Anesthesia (BBSA) study: a double-blinded, placebo-controlled, multicenter trial with 1-year follow-up. Anesthesiology , 2007, 107(1): 33-44.
8. van Klei WA, Bryson GL, Yang H, et al . Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology , 2009, 111(4): 717-724.
9. Poldermans D, Boersma E, Bax JJ, et al . Bisoprolol reduces cardiac death and myocardial infarction in high-risk patients as long as 2 years after successful major vascular surgery. Eur Heart J , 2001, 22(15): 1353-1358.
10. Raby KE, Brull SJ, Timimi F, et al . The effect of heart rate control on myocardial ischemia among high-risk patients after vascular surgery. Anesth Analg , 1999, 88(3): 477-482.
11. Zaugg M, Tagliente T, Lucchinetti E, et al . Beneficial effects from beta-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology , 1999, 91(6): 1674-1686.
12. Brady AR, Gibbs JS, Greenhalgh RM, et al . Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. J Vasc Surg , 2005, 41(4): 602-609.
13. Yang H, Raymer K, Butler R, et al . The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J , 2006, 152(5): 983-990.
14. POISE Study Group, Devereaux PJ, Yang H, et al . Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet , 2008, 371(9627): 1839-1847.
15. 赖仁纯, 许梅曦, 黄文起, 等. 美托洛尔对老年食管癌患者围手术期心脏功能的保护作用. 癌症, 2006, 25(5): 609-613.
16. 刘瑶, 黄昌林, 贺民, 等. 围手术期美托洛尔对老年非心脏手术病人血流动力学及心肌缺血的影响. 中南大学学报(医学版), 2006, 31(2): 2491.
17. Urban MK, Markowitz SM, Gordon MA, et al . Postoperative prophylactic administration of beta-adrenergic blockers in patients at risk for myocardial ischemia. Anesth Analg , 2000; 90(6): 1257-1261.
18. Bayliff CD, Massel DR, Inculet RI, et al . Propranolol for the prevention of postoperative arrhythmias in general thoracic surgery. Ann Thorac Surg , 1999, 67(1): 182-186.
19. Juul AB, Wetterslev J, Gluud C, et al . Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ , 2006, 332(7556): 1482.
20. Schouten O, Bax JJ, Dunkelgrun M, et al . Pro: Beta-blockers are indicated for patients at risk for cardiac complications undergoing noncardiac surgery. Anesth Analg , 2007, 104(1): 8-10.
21. Sipahi I, Tuzcu EM, Wolski KE, et al . Beta-blockers and progression of coronary atherosclerosis: pooled analysis of 4 intravascular ultrasonography trials. Ann Intern Med , 2007, 147(1): 10-18.
22. Lemaitre RN, Heckbert SR, Sotoodehnia N, et al . beta1- and beta2-adrenergic receptor gene variation, beta-blocker use and risk of myocardial infarction and stroke. Am J Hypertens , 2008, 21(3): 290-296.
23. Fleisher LA, Beckman JA, Brown KA, ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology. J Am Coll Cardiol , 2006, 47(11): 2343-2355.
24. Kaafarani HM, Atluri PV, Thornby J, et al . beta-Blockade in noncardiac surgery: outcome at all levels of cardiac risk. Arch Surg , 2008, 143(10):940-944.
25. Redelmeier D, Scales D, Kopp A. Beta blockers for elective surgery in elderly patients: population based, retrospective cohort study. BMJ , 2005, 331(7522): 932.
26. Lindenauer PK, Pekow P, Wang K, et al . Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med , 2005, 353(4): 349-361.
27. Bangalore S, Wetterslev J, Pranesh S, et al . Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. Lancet , 2008, 372(9654): 1962-1976.
28. Devereaux PJ, Goldman L, Yusuf S, et al . Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review. CMAJ , 2005, 173(7): 779-788.
29. Wallace A, Layug B, Tateo I, et al . Prophylactic atenolol reduces postoperative myocardial ischemia. McSPI Research Group. Anesthesiology , 1998, 88(1): 7-17.
30. Chopra V, Eagle KA. Perioperative beta-blockers for cardiac risk reduction: time for clarity. JAMA , 2010, 303(6): 551-552.
31. Kadoi Y, Saito S. Possible indications of beta-blockers in the perioperative period other than prevention of cardiac ischemia. J Anesth , 2010, 24(1): 81-95.
32. Stephens S. State of the science: beta-blockers and reduction of perioperative cardiac events. Crit Care Nurs Clin North Am , 2010, 22(2): 209-215.

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Efficacy of Tight Heart Rate Control for Perioperative Myocardial Protection: A Systematic Review

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