Summary of findings for the main comparison. Perioperative beta‐blockers compared to placebo or standard care for preventing surgery‐related mortality and morbidity in adults undergoing non‐cardiac surgery.
| Perioperative beta‐blockers compared to placebo or standard care for preventing mortality and morbidity in adults undergoing non‐cardiac surgery | |||||
| Population: adults undergoing non‐cardiac surgery under general anaesthesia (to include: low‐risk, medium‐risk, and high‐risk surgeries) Setting: hospitals in: Argentina, Australia, Bangladesh, Brazil, Canada, China, Columbia, Cuba, Denmark, Egypt, Equador, El Salvador, Finland, France, Ghana, Greece, Hong Kong, Hungary, India, Italy, Japan, South Korea, Malaysia, Mexico, Nepal, New Zealand, Norway, Peru, Singapore, Spain, Sweden, Switzerland, Thailand, Taiwan, Turkey, UK, USA Intervention: beta‐blockers (to include: propranolol, metoprolol, esmolol, landiolol, nadolol, atenolol, labetalol, oxprenolol, and pindolol) Comparison: placebo or standard care | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect (95% CI) | Number of participants (studies) | Certainty of the evidence (GRADE) | |
| Risk with placebo or standard care | Risk with beta‐blockers | ||||
|
Early all‐cause mortality (within 30 days) |
Study population | RR 1.17 (0.89 to 1.54) | 11,446 (16 studies) | ⊕⊕⊝⊝ Lowa |
|
| 25 per 1000 | 29 per 1000 (22 to 38) | ||||
|
Acute myocardial infarction (within 30 days) |
Study population | RR 0.72
(0.60 to 0.87) NNTB: 74 (52 to 160) |
10,520 (12 studies) | ⊕⊕⊝⊝ Lowb |
|
| 48 per 1000 | 35 per 1000 (29 to 42) | ||||
|
Cerebrovascular events (within 30 days) |
Study population | RR 1.65 (0.97 to 2.81) |
9460 (6 studies) | ⊕⊕⊝⊝ Lowc |
|
| 5 per 1000 | 8 per 1000 (5 to 14) | ||||
|
Ventricular arrhythmias (within 30 days) |
Study population | RR 0.72 (0.35 to 1.47) | 476 (5 studies) | ⊕⊝⊝⊝ Very lowd |
|
| 101 per 1000 | 73 per 1000 (35 to 149) | ||||
|
Atrial fibrillation or atrial flutter, or both (within 30 days) |
Study population | RR 0.41
(0.21 to 0.79) NNTB: 39 (29 to 108) |
9080 (9 studies) | ⊕⊕⊝⊝ Lowe |
|
| 44 per 1000 | 18 per 1000 (9 to 35) | ||||
|
Bradycardia (within 30 days; as defined by study authors, minimum heart rate < 60 beats per minute or requiring medication) |
Study population | RR 2.49
(1.74 to 3.56) NNTH: 18 (11 to 37) |
12,239 (49 studies) | ⊕⊕⊝⊝ Lowf |
|
| 37 per 1000 | 92 per 1000 (65 to 132) | ||||
|
Hypotension (within 30 days; as defined by study authors, minimum systolic blood pressure < 90 mmHg or requiring medication) |
Study population | RR 1.40
(1.29 to 1.51) NNTH: 23 (18 to 31) |
12,304 (49 studies) | ⊕⊕⊕⊝ Moderateg |
|
| 110 per 1000 | 154 per 1000 (142 to 166) | ||||
| *The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio; NNTB: number needed to treat for an additional beneficial outcome; NNTH: number needed to treat for an additional harmful outcome | |||||
| GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect. | |||||
aWe downgraded by two levels: one for study limitations because we assessed 10 studies to be at high risk of bias in at least one domain, and the effect estimate was not robust when we excluded studies of poorer methodological standards in sensitivity analysis; and one for inconsistency because we noted that one large study demonstrated an increase in mortality that was not replicated in the remaining smaller studies. bWe downgraded by two levels: one level for study limitations because we assessed eight studies to be at high risk of bias in at least one domain; and one level for inconsistency because we noted that one large study demonstrated a protective effect that was not replicated in the remaining smaller studies. cWe downgraded by two levels. We downgraded by one level for inconsistency because we noted differences in the effect between studies; in particular, one large study demonstrated an increase in cerebrovascular events that was not replicated in the remaining smaller studies. We also downgraded by one level for study limitations; the effect estimate was not robust when we excluded studies with poorer methodological standards in sensitivity analysis. dWe downgraded by three levels: one level for imprecision because the evidence was from too few participants and few single centre studies, one level for inconsistency because we noted a moderate level of statistical heterogeneity that we were unable to explain, and one level for study limitations because we judged several studies to be at high or unclear risk of bias. eWe downgraded by two levels: one level owing to inconsistency because we were unable to effectively assess or explain the substantial statistical heterogeneity that we noted for this outcome, and one level for study limitations because the effect estimate was not robust when we excluded studies with poorer methodological standards in sensitivity analysis. fWe downgraded by two levels: one level for study limitations because we assessed several studies to be at high or unclear risk of bias, and one level for inconsistency owing to substantial statistical heterogeneity that we were unable to explain from subgroup analyses. gWe downgraded by one level for study limitations because we assessed several studies to be at high or unclear risk of bias.