POISE Trial

[diceksox]

I was curious what the attednings/ upper year residents thought of this study (May, Lancet). Basically, they reported a decreased incidence of MI but increased risk of (all cause) mortality in patients with CAD or risk factors who received perioperative metoprolol prior to noncardiac surgery(100mg given between 2-4 hours before surgery, 6h after, and then BID for 30 days, you can read the study for the details.)
I know the consensus on perioperative beta blockade is frequently being augmented or changing with the recent studies popping up. What I would like to know is how you as attendings (or senior residents) will intepret and use this most recent study. Will you continue to abide strictly by the ACC/AHA guidelines (if you do currently), or will you change your practice.

And do you think this study is even applicable as 100mg metoprolol bid is a pretty descent starting dose.

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[cchoukal]

Martin London (UCSF) wrote an interesting editorial in last month's A/A summarizing some of the initial (as yet unpublished) results from POISE, and from what I gathered from that, the compelling outcome is that the benefits (reduced cardiac death, MI, and cardiac arrest) were balanced by increases in all cause death, stroke, and sepsis...

His read is certainly more well thought out than mine...

http://www.anesthesia-analgesia.org/cgi/reprint/106/4/1025

 

[militarymd]

prevalence of endpoints were all pretty low....5% or less.....

what does this mean???? i don't know

 

[militarymd]

no other comments/thoughts on this??

 

[starsop93]

I'm not at all surprised as the original Mangano and Poldermans studies were both highly flawed.

The Mangano study had a much sicker population in the placebo group. The Poldermans study had outrageously better outcomes in the study group and was halted based on that, but this has never been reproduced and almost certainly would have been less impressive if continued to completion.

This study is also a little hard to interpret as well given the whopping dose of metoprolol given, which I'm sure few of us ever approach as a starting dose. That being said, they make a good argument that few studies fully beta block anyone, and this dose should do it.

Overall, I think it makes sense that keeping the HR low and preventing bouts of tachycardia would be good for those at risk of a coronary event. That must be balanced by the fact that the selective beta blockers most of us use for this (esmolol, metroprolol, atenolol) theoretically do nothing for the blood pressure in these situations and may actually cause an increase in it (due to lack of beta 2 and alpha blockade). This might result in the higher risk of stroke they saw.

I will continue to use them as I have with the goal of preventing tachycardia without trashing any other hemodynamic variables, but I think it is great that this is being discussed again. The data never was as strong as it has been touted, so it deserves being looked at again.

 

[seinfeld]

Thank goodness for all this controversy. takes away simple algorithms and requires the training and thoughtfulness of a physician to treat patients.


Several points:
1. Nothing in medicine is for free. If you want to protect the brain and send it into burst suppression with thiopental you cant safely do it without being prepared to support BP. And when you support bp with your vasoconstrictor of choice youre not making the body "normal" again with a normal bp. There are things at play within the body that we dont understand. Perhaps the decreased Myocardial energy expenditure, although good in protecting the heart, causes such a decrease in Cardiac Output that other organs acutely become deprived of their normal oxygen and nutrient delivery. Perhaps B1 receptors exist in places we dont know about yet.

2. The public and clinicians are taught to care about the heart first before other organs. Based on this study ICU doc’s should never use Beta blockers in the ICU as it may increase the risk of developing sepsis. A neurologist should never advocate their use based on CVA tendency (BTW I remember some people implicating Labetalol as the cause of CVA in the beach chair position for ortho cases). But because we are trained to be more sensitive to issue of the heart we will likely feel compelled to beta block to prevent MI (I am not saying wanting to prevent MI is a bad thing)

3. i am amazed that people continue to conduct studies of perioperative medicine but never cite the incidence of intraoperative events. IF they report that the beta blocker group was more likely to be hypotensive during anesthesia perhaps we, as anesthesiologists, would have a clue as to why the secondary markers are higher. Do people who are placed on beta blockers by PCP for HTN also have increased of complications ?

In the end ....beta blockers? I don’t know what to do routinely other than keep them going in patients who are already on them. I take it on a case by case basis based on pt predictors, surgery type, and overall impression of badness. I must say that the same controversy seems to be apparent with insulin therapy.