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• W2043292561 abstract "Independent researchers have produced a new guideline on β blockers to replace what they say is outdated and unsafe advice by the European Society of Cardiology. Lilian Anekwe reports. Cardiology researchers have produced new independent guidelines in an attempt to replace the disputed European Society of Cardiology (ESC) guidelines on the use of perioperative β blockers in non-cardiac surgery. Contrary to the controversial ESC guidelines, the alternative guidelines published in the International Journal of Cardiology state that “beta-blockade should not be routinely initiated for perioperative protection because trial data indicate an increase in mortality”. The independent guidelines are authored by researchers from Imperial College London, UK. Their earlier meta-analysis published in Heart suggested that the ESC's recommendations to use β blockers periopeoratively in high-risk patients having non-cardiac surgery could be associated with a 27% increase in mortality. A subsequent commentary which estimated that the guidelines had potentially resulted in hundreds of thousands of excess deaths was pulled from the European Heart Journal (EHJ) website after publication and is yet to be republished. The data on which the ESC guidelines are based have been openly questioned by cardiologists. They are heavily based on the DECREASE trials led by Don Poldermans, the former chair of the ESC perioperative guidelines task force, who was dismissed after an investigation in 2011 found widespread “academic misconduct” and that much of the data had been fabricated. So far only one Poldermans paper has been retracted. Darrel Francis and Graham Cole tell The Lancet: “Our urgent focus remains on making guidelines safe. Many other calculations [of excess mortality] are possible, but time diverted quibbling over a number would be better spent safeguarding patient survival.” They add: “Since our meta-analysis, we have published the [presently] retracted article, drafted a new guideline restricted to reliable trials, and presented a major proposal to the EHJ regarding all future guidelines, to protect patients from recurrences.” This month the EHJ published an editorial in a bid to avoid public “panic”, which warned that “jumping to conclusions may be particularly dangerous for both physicians and patients”. The ESC is currently working on revised guidelines that are due to be published in August. Thomas Lüscher, editor-in-chief of the EHJ, tells The Lancet: “It's quite clear that the Poldermans data has doubts about it that we need to clarify through a review of the data. The dilemma for doctors now is should they stop a β blocker if people have already started, or start a β blocker in high-risk patients? This is a dilemma we cannot solve without a new trial. It's difficult to write definitive statements other than to ask doctors to make individual judgments.” The ESC's current position is that β blockers “should not be considered routine, but should be considered carefully by each patient's treating physician on a case-by-case basis”. Doctors question whether this position is instructive. Masood Khan, clinical lead in cardiology at Watford General Hospital, UK, says: “Simply suggesting we make a decision for an individual patient is what we always do. The [ESC] guideline does not reflect the concerns about the data that have emerged in the past few years. Although the guideline says you should give a β blocker increasingly we're deciding not to.” Researchers called for the guidelines to be urgently rewritten. Peter McCullough, a cardiologist at the Baylor Heart and Vascular Institute and editor of Reviews in Cardiovascular Medicine, says: “β blockers are probably useful in a subgroup of people who have myocardial infarctions caused by severe blockages in the arteries. But looking back to the DECREASE trials there are a number of things about the design of them that seem now totally unrealistic. I think in hindsight we were very much led astray by data that in retrospect seems fanciful.” Philip Devereux, an associate professor in cardiology at McMaster University, ON, Canada, led the POISE study which found the use of perioperative β blockers resulted in a significant excess risk of stroke and death. He says: “I don't think there was an intention to harm patients. People feel very uneasy about saying ‘maybe we got it dead wrong’, especially when it affects a lot of people. It's such a large population, so the implication is that much greater. Even one patient would be one too many. But given that we're causing serious problems, why would you keep the same position? It's unacceptable.” Lüscher says: “It has taken too long to review the guidelines but in big societies it's a slow process. But if physicians do their job according to their clinical experience, they won't be too far off. Guidelines don't detach us from our personal responsibilities to our patients, and should always be critically assessed by doctors and applied individually.” For the ESC guideline see European Heart Journal 2009; 30: 2769–2812For the new guideline in the International Journal of Cardiology see http://www.ncbi.nlm.nih.gov/pubmed/24486062For the meta-analysis in Heart see http://heart.bmj.com/content/early/2013/07/30/heartjnl-2013-304262.abstract For the ESC guideline see European Heart Journal 2009; 30: 2769–2812 For the new guideline in the International Journal of Cardiology see http://www.ncbi.nlm.nih.gov/pubmed/24486062 For the meta-analysis in Heart see http://heart.bmj.com/content/early/2013/07/30/heartjnl-2013-304262.abstract" @default.
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• W2043292561 title "New guideline on β blockers challenges ESC advice" @default.
• W2043292561 doi "https://doi.org/10.1016/s0140-6736(14)60243-9" @default.
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