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all-cause mortality&#59; acute myocardial infarction &#40;AMI&#41;&#59; myocardial ischemia&#59; cerebrovascular events&#59; hypotension&#59; bradycardia&#59; congestive heart failure&#59; ventricular arrhythmias&#59; supraventricular arrhythmias&#59; length of hospital stay&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors performed a comprehensive database analysis for trials fulfilling the inclusion criteria &#40;Cochrane Central Register of Controlled Trials &#91;CENTRAL&#93;&#44; MEDLINE&#44; EMBASE&#44; Biosis Previews&#44; CAB Abstracts&#44; Cumulative Index to Nursing and Allied Health Literature &#91;CINAHL&#93;&#44; Derwent Drug File&#44; Science Citation Index Expanded&#44; Life Sciences Collection&#44; Global Health and PASCAL&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Eighty-eight RCTs with 19 161 participants were included &#40;53 trials on cardiac surgery and 35 trials on non-cardiac surgery&#41;&#46; Outcomes were assessed separately for cardiac and non-cardiac surgery&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Regarding cardiac surgery&#44; beta-blockers had a protective effect against supraventricular and ventricular arrhythmias&#46; There was no evidence of an effect on death&#44; the occurrence of AMI&#44; stroke or heart failure&#44; or the development of disproportionately low blood pressure or bradycardia during surgery&#46; Length of hospital stay after heart surgery was reduced by about 0&#46;5 days in patients taking beta-blockers &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In non-cardiac surgery&#44; beta-blockers increased the risk of death and stroke&#44; the latter only when a representative group of high-quality trials was analyzed&#46; The protective effect against AMI and rhythm disturbances was counterbalanced by this increased risk of death and stroke &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; perioperative use of beta-blockers appears beneficial overall in cardiac surgery&#44; particularly concerning the risk of ventricular and supraventricular arrhythmias&#46; In non-cardiac surgery&#44; the evidence shows an increase in death and a potential increase in stroke with the use of these drugs&#46; The substantial reduction in rhythm disturbances and AMI in this setting appears to be offset by this potential increase in mortality and stroke&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Comments</span><p id="par0045" class="elsevierStylePara elsevierViewall">This systematic review presents the best available evidence on the controversial topic of the perioperative use of beta-blockers in cardiac or non-cardiac surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Perioperative cardiovascular complications are an important concern because 2&#37; of patients suffer major cardiac complications&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> and 8&#37; show evidence of significant myocardial injury&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The perioperative use of beta-blockers was initially seen as a potential way to decrease the risk of perioperative cardiovascular complications&#44; particularly after the publication of two RCTs with positive results&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">4&#44;5</span></a> On the basis of this evidence&#44; the first versions of the clinical practice guidelines recommended the use of beta-blockers in the perioperative period in patients undergoing non-cardiac surgery&#46; Nonetheless&#44; for various reasons&#44; the strength and scope of these recommendations have decreased in later versions of the guidelines&#46; First&#44; the benefits of perioperative beta-blockers could not be reproduced in other RCTs&#46; Second&#44; the POISE-1 trial&#44; which enrolled 9000 participants&#44; showed that the use of beta-blockers decreased the risk of perioperative AMI but increased the risks of death&#44; stroke&#44; bradycardia and hypotension&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> These adverse events were likely related to one of the major criticisms of the POISE-1 trial&#44; namely starting long-acting beta blockers at high doses shortly prior to surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> Third&#44; the validity of work led by the Dutch investigator Don Poldermans has come under scrutiny&#44; and two RCTs &#40;the DECREASE trials&#41; with positive results have been retracted due to concerns about scientific misconduct&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5&#44;7</span></a> Consequently&#44; the guidelines re-evaluated these data and excluded them from the background evidence used to set recommendations for perioperative beta-blockade&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">As an example&#44; the American College of Cardiology &#40;ACC&#41;&#47;American Heart Association &#40;AHA&#41; guidelines supported their recommendations by their own systematic review on this topic&#44; from which they excluded the two DECREASE trials&#46; The review identified 16 RCTs including 12 043 participants and the pooled results showed that prophylactic beta-blocker use resulted in 17 fewer cases of AMI&#44; at the cost of four excess strokes and six deaths for every 1000 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> Nevertheless&#44; the review identified major limitations&#58; no valid trials assessed beta-blockade that was started more than 24 hours before surgery&#44; and very few trials assessed agents aside from metoprolol&#46; Therefore&#44; the ACC&#47;AHA guidelines advise against initiating beta-blocker therapy in the 24 hours before surgery&#46; Based on observational studies&#44; starting beta-blocker therapy might be considered in patients at high cardiovascular risk or with reversible ischemia detected on stress testing&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Importantly&#44; the above discussion is mostly relevant to patients beginning beta-blockers de novo&#44; and does not apply to patients previously treated with beta-blockers&#46; As withdrawal of chronic therapy is associated with an increase in the risk of cardiovascular events and death&#44; beta-blocker therapy should be continued&#44; although modification of perioperative doses or discontinuation may be required to address changing clinical circumstances such as hypotension&#44; bradycardia&#44; or massive blood loss&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The current European Society of Cardiology guidelines on non-cardiac surgery only recommend beta-blocker therapy &#40;preferably with atenolol or bisoprolol based on observational studies&#41;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">9-11</span></a> in high-risk patients undergoing high-risk surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> Based on clinical judgment and evidence from small trials&#44; beta-blockers should be initiated and titrated in order to achieve a heart rate between 60 and 70 bpm and to avoid a systolic blood pressure below 100 mmHg&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The clinical question posed here clearly needs to be answered with new randomized controlled trials to determine &#40;1&#41; which patients derive benefit from beta-blocker therapy in the perioperative setting&#59; &#40;2&#41; if there is a class effect or whether there is a single best beta-blocker &#40;if any&#41; for this setting&#59; &#40;3&#41; what is the best time to start beta-blockers&#44; or what is the period of greatest risk&#59; and &#40;4&#41; what are the optimum doses and&#47;or hemodynamic targets &#40;including blood pressure and heart rate&#41; for beta-blocker therapy&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In cardiac surgery&#44; there are many situations in which beta-blockers are already indicated&#46; However&#44; in addition&#44; beta-blockers may be useful to decrease the risk of supraventricular &#40;including atrial fibrillation&#41; and ventricular arrhythmias that may result from increased sympathetic tone following surgery&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Randomized controlled trials have yielded conflicting results regarding the impact of beta-blockers on perioperative cardiovascular morbidity and mortality&#46; This Cochrane systematic review assessed the impact of this intervention on mortality and cardiovascular events&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Eighty-eight randomized controlled trials with 19 161 participants were included &#40;53 trials on cardiac surgery and 35 trials on non-cardiac surgery&#41;&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In cardiac surgery perioperative beta-blockers had a protective effect against supraventricular and ventricular arrhythmias but had no significant effect on mortality or on the occurrence of acute myocardial infarction &#40;AMI&#41;&#44; stroke&#44; heart failure&#44; hypotension or bradycardia&#46; In non-cardiac surgery&#44; beta-blockers had a protective effect against AMI and arrhythmias&#44; but this was counterbalanced by an increased risk of death and stroke&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In conclusion&#44; perioperative use of beta-blockers appears overall to be bene&#64257;cial in cardiac surgery&#46; However&#44; in non-cardiac surgery the substantial reduction in rhythm disturbances and AMI appears to be offset by an increase in mortality and stroke&#44; and so the systematic use of beta-blockers in this setting is not recommended&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Os resultados de ensaios cl&#237;nicos aleatorizados relativos &#224; utiliza&#231;&#227;o de betabloqueantes no per&#237;odo perioperat&#243;rio de cirurgia card&#237;aca e n&#227;o card&#237;aca t&#234;m sido controversos&#46; Esta revis&#227;o sistem&#225;tica da Cochrane avaliou o impacto dessa interven&#231;&#227;o na mortalidade e eventos cardiovasculares peri-operat&#243;rios&#46; Foram inclu&#237;dos 88 ensaios cl&#237;nicos aleatorizados com um total de 19 161 participantes &#40;53 ensaios com cirurgia card&#237;aca e 35 com cirurgia n&#227;o card&#237;aca&#41;&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A utiliza&#231;&#227;o perioperat&#243;ria de betabloqueantes na cirurgia card&#237;aca reduziu significativamente a ocorr&#234;ncia de disritmias supraventriculares e ventriculares&#44; sem impacto significativo na mortalidade&#44; bem como no risco de enfarte agudo do mioc&#225;rdio &#40;EAM&#41;&#44; acidente vascular cerebral &#40;AVC&#41;&#44; insufici&#234;ncia card&#237;aca&#44; hipotens&#227;o e bradicardia&#46; Por outro lado&#44; na cirurgia n&#227;o card&#237;aca&#44; apesar de existir uma redu&#231;&#227;o no risco de EAM e nos eventos arr&#237;tmicos supraventriculares&#44; esse efeito foi contrabalan&#231;ado pelo aumento do risco de morte e AVC&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Em conclus&#227;o&#44; a utiliza&#231;&#227;o de betabloqueantes no per&#237;odo perioperat&#243;rio de cirurgia card&#237;aca parece ser ben&#233;fica&#46; Por outro lado&#44; na cirurgia n&#227;o card&#237;aca apesar da redu&#231;&#227;o significativa de EAM e disritmias&#44; h&#225; um aumento da mortalidade e de AVC&#44; pelo que a utiliza&#231;&#227;o sistem&#225;tica de betabloqueantes em doentes submetidos a cirurgia n&#227;o card&#237;aca n&#227;o est&#225; recomendada&#46;</p></span>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Plot showing the results of the meta-analysis assessing the impact of beta-blockade on the outcomes of patients undergoing cardiac and non-cardiac surgery&#46; The quality of evidence as reported in the review<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a>&#58; low quality &#40;red&#41;&#44; moderate quality &#40;yellow&#41;&#44; and high quality &#40;green&#41;&#46; AMI&#58; acute myocardial infarction&#59; CI&#58; confidence interval&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
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          "bibliografiaReferencia" => array:14 [
            0 => array:3 [
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                      "titulo" => "Perioperative beta-blockers for preventing surgery-related mortality and morbidity"
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                          "etal" => true
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                      "titulo" => "Perioperative cardiac events in patients undergoing noncardiac surgery&#58; a review of the magnitude of the problem&#44; the pathophysiology of the events and methods to estimate and communicate risk"
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                        0 => array:2 [
                          "etal" => true
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                  "contribucion" => array:1 [
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                  ]
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                        0 => array:2 [
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                            0 => "D&#46; Poldermans"
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                          "etal" => true
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                            0 => "P&#46;J&#46; Devereaux"
                            1 => "H&#46; Yang"
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Original Article
Cochrane Corner: Perioperative beta-blockers for preventing surgery-related mortality and morbidity
Cochrane Corner: Utilização de betabloqueantes no período perioperatório para prevenção de mortalidade e morbilidade relacionadas com a cirurgia
Sofia Alegriaa, João Costab,c,d,e, António Vaz-Carneirob,c, Daniel Caldeirad,e,f,
Autor para correspondência
dgcaldeira@hotmail.com

Corresponding author.
a Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal
b Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
c Centro Colaborador Português da Rede Cochrane Iberoamericana, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
d Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
e Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
f Serviço de Cardiologia, Hospital Universitário de Santa Maria (CHLN), CAML, Centro Cardiovascular da Universidade de Lisboa - CCUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
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        "titulo" => "Cochrane Corner&#58; Utiliza&#231;&#227;o de betabloqueantes no per&#237;odo perioperat&#243;rio para preven&#231;&#227;o de mortalidade e morbilidade relacionadas com a cirurgia"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Plot showing the results of the meta-analysis assessing the impact of beta-blockade on the outcomes of patients undergoing cardiac and non-cardiac surgery&#46; The quality of evidence as reported in the review<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a>&#58; low quality &#40;red&#41;&#44; moderate quality &#40;yellow&#41;&#44; and high quality &#40;green&#41;&#46; AMI&#58; acute myocardial infarction&#59; CI&#58; confidence interval&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical question</span><p id="par0005" class="elsevierStylePara elsevierViewall">What is the impact of beta-blockers on perioperative adverse events&#63;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Description of review</span><p id="par0010" class="elsevierStylePara elsevierViewall">This is a systematic review of randomized controlled trials &#40;RCTs&#41; on the effects of perioperatively administered beta-blockers for prevention of surgery-related mortality and morbidity in patients undergoing any type of surgery while under general anesthesia&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The following outcomes were assessed&#58; all-cause mortality&#59; acute myocardial infarction &#40;AMI&#41;&#59; myocardial ischemia&#59; cerebrovascular events&#59; hypotension&#59; bradycardia&#59; congestive heart failure&#59; ventricular arrhythmias&#59; supraventricular arrhythmias&#59; length of hospital stay&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors performed a comprehensive database analysis for trials fulfilling the inclusion criteria &#40;Cochrane Central Register of Controlled Trials &#91;CENTRAL&#93;&#44; MEDLINE&#44; EMBASE&#44; Biosis Previews&#44; CAB Abstracts&#44; Cumulative Index to Nursing and Allied Health Literature &#91;CINAHL&#93;&#44; Derwent Drug File&#44; Science Citation Index Expanded&#44; Life Sciences Collection&#44; Global Health and PASCAL&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Eighty-eight RCTs with 19 161 participants were included &#40;53 trials on cardiac surgery and 35 trials on non-cardiac surgery&#41;&#46; Outcomes were assessed separately for cardiac and non-cardiac surgery&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Regarding cardiac surgery&#44; beta-blockers had a protective effect against supraventricular and ventricular arrhythmias&#46; There was no evidence of an effect on death&#44; the occurrence of AMI&#44; stroke or heart failure&#44; or the development of disproportionately low blood pressure or bradycardia during surgery&#46; Length of hospital stay after heart surgery was reduced by about 0&#46;5 days in patients taking beta-blockers &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In non-cardiac surgery&#44; beta-blockers increased the risk of death and stroke&#44; the latter only when a representative group of high-quality trials was analyzed&#46; The protective effect against AMI and rhythm disturbances was counterbalanced by this increased risk of death and stroke &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; perioperative use of beta-blockers appears beneficial overall in cardiac surgery&#44; particularly concerning the risk of ventricular and supraventricular arrhythmias&#46; In non-cardiac surgery&#44; the evidence shows an increase in death and a potential increase in stroke with the use of these drugs&#46; The substantial reduction in rhythm disturbances and AMI in this setting appears to be offset by this potential increase in mortality and stroke&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Comments</span><p id="par0045" class="elsevierStylePara elsevierViewall">This systematic review presents the best available evidence on the controversial topic of the perioperative use of beta-blockers in cardiac or non-cardiac surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Perioperative cardiovascular complications are an important concern because 2&#37; of patients suffer major cardiac complications&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> and 8&#37; show evidence of significant myocardial injury&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The perioperative use of beta-blockers was initially seen as a potential way to decrease the risk of perioperative cardiovascular complications&#44; particularly after the publication of two RCTs with positive results&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">4&#44;5</span></a> On the basis of this evidence&#44; the first versions of the clinical practice guidelines recommended the use of beta-blockers in the perioperative period in patients undergoing non-cardiac surgery&#46; Nonetheless&#44; for various reasons&#44; the strength and scope of these recommendations have decreased in later versions of the guidelines&#46; First&#44; the benefits of perioperative beta-blockers could not be reproduced in other RCTs&#46; Second&#44; the POISE-1 trial&#44; which enrolled 9000 participants&#44; showed that the use of beta-blockers decreased the risk of perioperative AMI but increased the risks of death&#44; stroke&#44; bradycardia and hypotension&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> These adverse events were likely related to one of the major criticisms of the POISE-1 trial&#44; namely starting long-acting beta blockers at high doses shortly prior to surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> Third&#44; the validity of work led by the Dutch investigator Don Poldermans has come under scrutiny&#44; and two RCTs &#40;the DECREASE trials&#41; with positive results have been retracted due to concerns about scientific misconduct&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5&#44;7</span></a> Consequently&#44; the guidelines re-evaluated these data and excluded them from the background evidence used to set recommendations for perioperative beta-blockade&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">As an example&#44; the American College of Cardiology &#40;ACC&#41;&#47;American Heart Association &#40;AHA&#41; guidelines supported their recommendations by their own systematic review on this topic&#44; from which they excluded the two DECREASE trials&#46; The review identified 16 RCTs including 12 043 participants and the pooled results showed that prophylactic beta-blocker use resulted in 17 fewer cases of AMI&#44; at the cost of four excess strokes and six deaths for every 1000 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> Nevertheless&#44; the review identified major limitations&#58; no valid trials assessed beta-blockade that was started more than 24 hours before surgery&#44; and very few trials assessed agents aside from metoprolol&#46; Therefore&#44; the ACC&#47;AHA guidelines advise against initiating beta-blocker therapy in the 24 hours before surgery&#46; Based on observational studies&#44; starting beta-blocker therapy might be considered in patients at high cardiovascular risk or with reversible ischemia detected on stress testing&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Importantly&#44; the above discussion is mostly relevant to patients beginning beta-blockers de novo&#44; and does not apply to patients previously treated with beta-blockers&#46; As withdrawal of chronic therapy is associated with an increase in the risk of cardiovascular events and death&#44; beta-blocker therapy should be continued&#44; although modification of perioperative doses or discontinuation may be required to address changing clinical circumstances such as hypotension&#44; bradycardia&#44; or massive blood loss&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The current European Society of Cardiology guidelines on non-cardiac surgery only recommend beta-blocker therapy &#40;preferably with atenolol or bisoprolol based on observational studies&#41;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">9-11</span></a> in high-risk patients undergoing high-risk surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> Based on clinical judgment and evidence from small trials&#44; beta-blockers should be initiated and titrated in order to achieve a heart rate between 60 and 70 bpm and to avoid a systolic blood pressure below 100 mmHg&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The clinical question posed here clearly needs to be answered with new randomized controlled trials to determine &#40;1&#41; which patients derive benefit from beta-blocker therapy in the perioperative setting&#59; &#40;2&#41; if there is a class effect or whether there is a single best beta-blocker &#40;if any&#41; for this setting&#59; &#40;3&#41; what is the best time to start beta-blockers&#44; or what is the period of greatest risk&#59; and &#40;4&#41; what are the optimum doses and&#47;or hemodynamic targets &#40;including blood pressure and heart rate&#41; for beta-blocker therapy&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In cardiac surgery&#44; there are many situations in which beta-blockers are already indicated&#46; However&#44; in addition&#44; beta-blockers may be useful to decrease the risk of supraventricular &#40;including atrial fibrillation&#41; and ventricular arrhythmias that may result from increased sympathetic tone following surgery&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Randomized controlled trials have yielded conflicting results regarding the impact of beta-blockers on perioperative cardiovascular morbidity and mortality&#46; This Cochrane systematic review assessed the impact of this intervention on mortality and cardiovascular events&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Eighty-eight randomized controlled trials with 19 161 participants were included &#40;53 trials on cardiac surgery and 35 trials on non-cardiac surgery&#41;&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In cardiac surgery perioperative beta-blockers had a protective effect against supraventricular and ventricular arrhythmias but had no significant effect on mortality or on the occurrence of acute myocardial infarction &#40;AMI&#41;&#44; stroke&#44; heart failure&#44; hypotension or bradycardia&#46; In non-cardiac surgery&#44; beta-blockers had a protective effect against AMI and arrhythmias&#44; but this was counterbalanced by an increased risk of death and stroke&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In conclusion&#44; perioperative use of beta-blockers appears overall to be bene&#64257;cial in cardiac surgery&#46; However&#44; in non-cardiac surgery the substantial reduction in rhythm disturbances and AMI appears to be offset by an increase in mortality and stroke&#44; and so the systematic use of beta-blockers in this setting is not recommended&#46;</p></span>"
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