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β-blockade to prevent perioperative death in non-cardiac surgery: questions, controversy, and not enough answers
  1. Prashant Vaishnava,
  2. Kim A Eagle
  1. The Department of Internal Medicine, The Division of Cardiovascular Medicine, The University of Michigan Health System, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Prashant Vaishnava, 1500 East Medical Center Drive, Cardiovascular Center, Office 2706-SPC 5853, Ann Arbor, MI 48109, USA; pvaishna{at}umich.edu

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The use of perioperative β-blockade in patients undergoing non-cardiac surgery are informed, in part, by the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) family of studies.1 Allegations of research fraud have discredited the DECREASE studies and diluted the evidence supporting the cardiovascular benefit of perioperative β blockade.2–4 All studies investigated in the DECREASE family were found to be insecure because of flaws ranging from fictitious methods to fabrication of data to no evidence of written informed consent.3 ,4 Current European and American guidelines continue to offer Class I recommendations for continuation of pre-existing β-blockade,5 ,6 and initiation of β-blockade in those patients known to have ischaemic heart disease or myocardial ischaemia according to preoperative testing,5 and those undergoing high-risk (primarily vascular) surgery.5

Recognising the limitations of the flawed DECREASE data, Bouri et al3 performed a meta-analysis of secure intention-to-treat randomised controlled trial (RCT) data of β-blockade on perioperative mortality, non-fatal myocardial infarction, stroke and hypotension in patients undergoing non-cardiac surgery. Studies from the DECREASE family of studies were excluded; the meta-analysis included 10 529 patients from nine secure trials. Initiation of a course of β-blockade before surgery was associated with a significant 27% increase in mortality (relative risk (RR) 1.27, 95% CI 1.01 to 1.60, p=0.04). β-blockade reduced non-fatal myocardial infarction (RR …

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