American College of Cardiology
American College of Cardiology
March 14, 2018
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POISE: Higher death, stroke risk persists 1 year after noncardiac surgery in patients treated with metoprolol

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PJ Devereaux
P.J. Devereaux

ORLANDO, Fla. — At 1 year, for every 1,000 patients undergoing noncardiac surgery, treatment with the beta-blocker metoprolol would prevent 12 patients from experiencing an MI and six from undergoing cardiac revascularization, but result in an excess of 13 deaths and six strokes, P.J. Devereaux, MD, PhD, FRCP(C), reported at the American College of Cardiology Scientific Session.

Previous data from the POISE trial at 30 days after surgery showed similar findings — a reduction in MI, but increases in death and stroke.

Devereaux and colleagues evaluated outcomes at 1-year follow-up among 8,351 patients in 23 countries with increased risk for atherosclerotic CVD who were undergoing noncardiac surgery, most commonly vascular surgery, followed by intraperitoneal, orthopedic or other surgeries. Patients were assigned to receive metoprolol CR (n = 4,174; mean age, 69 years; 63% men) or placebo (n = 4,177; mean age, 69 years; 64% men). Metoprolol 100 mg was given 2 to 4 hours before surgery and again 6 hours after. One day after surgery, metoprolol was increased to 200 mg and continued daily for 30 days. Dose was decreased to 100 mg per day in patients developed hypotension or bradycardia.

At baseline, mean preoperative heart rate was 78 beats per minute and mean preoperative BP was 139/78 mm Hg in the metoprolol group and 139/79 mm Hg in the placebo group.

“Patients were not starting off with low blood pressures or heart rates. They were more predisposed to higher rates,” Devereaux, director of the division of cardiology at McMaster University in Hamilton, Ontario, said during the presentation.

At 1 year, all-cause mortality was reported in 10% of the metoprolol group vs. 9% of the placebo group (HR = 1.16; 95% CI, 1.01-1.34) and non-CV mortality in 6% vs. 5%, respectively (HR = 1.22; 95% CI, 1.01-1.48). CV mortality was similar at 4% in both groups.

Fewer patients assigned metoprolol had an MI (5% vs. 6.2%; HR = 0.78; 95% CI, 0.65-0.94), but more strokes (2% vs. 1.4%; HR = 1.52; 95% CI, 1.09-2.12) were reported. Cardiac revascularization was also reduced in the metoprolol group (< 1% vs. 1%; HR = 0.47; 95% CI, 0.28-0.78). There was no statistical difference in nonfatal cardiac arrest and pulmonary embolism in the two groups.

“Research is needed to establish a way to derive the benefits of perioperative beta-blockade while mitigating the risk,” Devereaux said. – by Darlene Dobkowski

Reference:

Devereaux PJ, et al. Joint ACC/NEJM Late-Breaking Clinical Trials. Presented at: American College of Cardiology Scientific Session; March 10-12, 2018; Orlando, Fla.

Disclosure: Devereaux reports he receives research support from Abbott Diagnostics, Boehringer Ingelheim, Philips Healthcare and Roche Diagnostics.