Robert Roberts, MD
In patients with, or at risk for, atherosclerotic disease, does perioperative metoprolol succinate reduce 30-day risk for major cardiovascular events after noncardiac surgery?
Randomized placebo-controlled trial (PeriOperative ISchemic Evaluation [POISE]).
Blinded (patients, clinicians, data collectors, and outcome adjudicators).*
190 hospitals in 23 countries worldwide.
8351 patients ≥ 45 years of age (mean age 69 y, 63% men) who were having noncardiac surgery with an expected hospital stay ≥ 24 hours and fulfilled specific criteria indicating that they had, or were at risk for, atherosclerotic disease.
Oral extended-release metoprolol succinate (n = 4174) or placebo (n = 4177), 100 mg 2 to 4 hours before surgery and 6 hours after surgery (or earlier if heart rate was ≥ 80 bpm and systolic blood pressure was ≥ 100 mm Hg), then 200 mg daily for 30 days. Safety rules checked before each dosing ensured that patients did not receive the study drug if heart rate or systolic blood pressure was too low, and subsequent doses were decreased if these hemodynamics were low.
Composite endpoint (cardiovascular death, nonfatal myocardial infarction [MI], or nonfatal cardiac arrest). Secondary outcomes included MI, stroke, all-cause mortality, and clinically significant hypotension and bradycardia.
99.8% (intention-to-treat analysis).
Metoprolol reduced risk for the primary composite endpoint and MI but increased risk for stroke and all-cause mortality (Table).
In high-risk patients having noncardiac surgery, perioperative metoprolol succinate reduced short-term risk for myocardial infarction but increased risk for stroke and death.
Metoprolol succinate vs placebo to prevent cardiovascular events in patients having noncardiac surgery†
†Abbreviations defined in Glossary. RRR, RRI, NNT, NNH, and CI calculated from data in article.
‡Cardiovascular death (metoprolol vs placebo: 1.8% vs 1.4%), nonfatal myocardial infarction (3.6% vs 5.1%), or nonfatal cardiac arrest (0.5% vs 0.5%).
Roberts R. Metoprolol prevented myocardial infarction but increased risk for stroke and death after noncardiac surgery. Ann Intern Med. 2008;149:JC3–4. doi: 10.7326/0003-4819-149-6-200809160-02004
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Published: Ann Intern Med. 2008;149(6):JC3-4.
Acute Coronary Syndromes, Cardiology, Coronary Heart Disease, Coronary Risk Factors, Emergency Medicine.
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