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Evevident
Original paper
2008LancetSurgery/Perioperative

POISE

Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery

RCTPerioperative medicine

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Overview

Perioperative metoprolol reduced MI but increased stroke and death when started right before surgery.

Clinical takeaway

POISE is the perioperative beta-blocker cautionary trial: avoid reflexively starting high-dose beta blockers immediately before noncardiac surgery.

Key result

Metoprolol reduced MI but increased stroke and all-cause mortality.

Practice impact

Continue chronic beta blockers, but do not newly start high-dose beta blockers on the eve of surgery.

Evidence

Study design

Randomized, double-blind, placebo-controlled trial.

Enrollment

8,351

Follow-up

30 days.

Geography

Multinational

Clinical question

Does perioperative extended-release metoprolol reduce major cardiovascular events in patients undergoing noncardiac surgery?

Population

  • Adults undergoing noncardiac surgery with or at risk for atherosclerotic disease.

Intervention

Extended-release metoprolol succinate started 2-4 hours before surgery and continued postoperatively.

Comparator

Placebo.

Primary outcome

Composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal cardiac arrest.

Metoprolol reduced the primary ischemic composite but caused offsetting increases in stroke and death.

Hazard ratio / 0.84 / CI 95% CI 0.70-0.99 / p=0.0399

Key results

  • Primary composite was reduced with metoprolol.
  • Nonfatal myocardial infarction was reduced.
  • Stroke and all-cause mortality were increased with metoprolol.

Harms

  • Stroke was increased.
  • All-cause mortality was increased.
  • Clinically significant hypotension and bradycardia were more common.

Clinical Use

When to cite

  • When deciding whether to start beta blockers shortly before noncardiac surgery.

Practice impact

  • Changed perioperative practice away from initiating high-dose beta blockers immediately before surgery.

Applicability

  • Patients undergoing noncardiac surgery who are being considered for new perioperative beta blockade.

Limitations

  • Tested a high-dose, rapid-start regimen; it does not answer careful outpatient initiation weeks before surgery.
  • Does not argue against continuing chronic beta blockers.

Common misinterpretations

  • Do not stop a patient's chronic beta blocker because of POISE; the key harm is acute high-dose initiation without time to titrate.

Related evidence

BRIDGE - ContextMERIT-HF - Contrasting Result

Citation

POISE Study Group, Devereaux PJ, Yang H, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839-1847. doi:10.1016/S0140-6736(08)60601-7

Patients are unlikely to accept the risks associated with perioperative extended-release metoprolol.