Revista Biomédica Revisada Por Pares
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El betabloqueo en pacientes sometidos a cirugía no cardíaca ha sido ampliamente recomendado como una forma de disminuir los eventos adversos cardiovasculares durante el periodo perioperatorio. Sin embargo, los estudios han mostrado resultados discordantes. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples bases de datos, identificamos 22 revisiones sistemáticas que en conjunto incluyen 131 estudios, entre ellos 112 estudios aleatorizados. Extrajimos los datos, realizamos un metanálisis y preparamos tablas de resumen de los resultados utilizando el método GRADE. Concluimos que el uso perioperatorio de betabloqueadores en pacientes sometidos a cirugía no cardíaca, si bien probablemente disminuye el riesgo de infarto miocárdico, aumenta el riesgo de accidente cerebrovascular y la mortalidad total.
El aumento de catecolaminas que ocurre durante una cirugía no cardiaca [1] produce una elevación de la presión arterial y de la frecuencia cardíaca [2],[3],[4] que contribuye a la ocurrencia de eventos adversos cardiovasculares. Los betabloqueadores suprimen el efecto de la elevación de catecolaminas, por lo que se piensa que su administración en el periodo perioperatorio podría prevenir estos eventos. Los estudios iniciales mostraron resultados muy prometedores, lo cual llevó a que esta intervención fuera ampliamente recomendada para un gran espectro de pacientes sometidos a cirugía no cardíaca. No obstante, estudios posteriores no sólo matizaron el posible beneficio de administrar betabloqueadores en el periodo perioperatorio, sino que alertaron sobre posibles efectos adversos como accidente cerebrovascular, hipotensión y bradicardia, entre otros. A lo anterior se suma el cuestionamiento sobre la confiabilidad de ciertos estudios en que se fundamentaron las recomendaciones previas, ya que algunos autores han sido acusados de mala conducta científica. Por todas estas razones la decisión sobre si utilizar o no esta intervención es motivo de debate hasta el día de hoy.
Utilizamos la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples bases de datos, para identificar revisiones sistemáticas y sus estudios primarios incluidos. Con esta información generamos un resumen estructurado, siguiendo un formato preestablecido, que incluye mensajes clave, un resumen del conjunto de evidencia (presentado como matriz de evidencia en Epistemonikos), metanálisis del total de los estudios, tablas de resumen de resultados con el método GRADE, y tabla de otras consideraciones para la toma de decisión.
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Mensajes clave
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Cuál es la evidencia. |
Encontramos 22 revisiones sistemáticas[5],[6],[7],[8],[9], |
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Qué tipo de pacientes incluyeron los estudios |
Los 55 estudios incluyeron pacientes adultos sometidos a cualquier tipo de cirugía no cardíaca: cirugía digestiva (22%), cirugía vascular (22%), ginecológica (14,6%), torácica (12,2%), traumatológica (7,3%), neurológica (7,3%), otorrinolaringológica (4,9%), maxilofacial (4,9%), oral (2,4%) y cirugía de emergencia (2,4%). |
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Qué tipo de intervenciones incluyeron los estudios |
El tipo de betabloqueador más utilizado fue metoprolol (35,1%), luego esmolol (24,1%), atenolol (16,9%), labetalol (7,4%), bisoprolol (7,4%), propanolol (3,7%) y otros (landiolol, nadolol y timolol; 5,4%). |
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Qué tipo de desenlaces midieron |
Las revisiones sistemáticas identificadas agruparon los desenlaces de la siguiente forma:
El seguimiento postoperatorio de los pacientes en los distintos estudios varió desde el día del alta hospitalaria, hasta 30 días posteriores a la cirugía. |
La información sobre el efecto de los betabloqueadores está basada en 29 estudios aleatorizados que incluyen 12 644 pacientes, cuyos datos pudieron ser incorporados a un metanálisis. Todos los estudios midieron el desenlace mortalidad por cualquier causa [27],[28],[29],[31],[32],[33],[34],[36],[37],[38],[39], [40],[41],[42],[45],[46],[47],[52],[54],[56],[58],[59],[60],[62],[72],[74],[75],[77],[78], 26 estudios midieron el desenlace infarto miocárdico perioperatorio [27],[28],[29],[31],[33],[34],[39],[40],[41],[42],[45],[46],[47],[52],[54],[56],[58],[59],[60],[62],[63],[72],[74],[75],[77],[78] y 16 midieron accidentes cerebrovasculares [27],[28],[29],[40],[41],[42],[47],[56],[58],[59],[62],[72],[74],[75],[77],[78]. El resumen de los resultados es el siguiente.
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A quién se aplica y a quién no se aplica esta evidencia |
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| Sobre los desenlaces incluidos en este resumen |
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| Balance riesgo/beneficio y certeza de la evidencia |
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| Qué piensan los pacientes y sus tratantes |
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| Consideraciones de recursos |
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| Diferencias entre este resumen y otras fuentes |
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| ¿Puede que cambie esta información en el futuro? |
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Mediante métodos automatizados y colaborativos recopilamos toda la evidencia relevante para la pregunta de interés y la presentamos en una matriz de evidencia.
Siga el enlace para acceder a la versión interactiva: Betabloqueo perioperatorio en cirugía no cardíaca
Si con posterioridad a la publicación de este resumen se publican nuevas revisiones sistemáticas sobre este tema, en la parte superior de la matriz se mostrará un aviso de “nueva evidencia”. Si bien el proyecto contempla la actualización periódica de estos resúmenes, los usuarios están invitados a comentar en Medwave o contactar a los autores mediante correo electrónico si creen que hay evidencia que motive una actualización más rápida.
Luego de crear una cuenta en Epistemonikos, al guardar las matrices recibirá notificaciones automáticas cada vez que exista nueva evidencia que potencialmente responda a esta pregunta. El detalle de los métodos para elaborar este resumen están descritos aquí: http://dx.doi.org/10.5867/medwave.2014.06.5997.
La Fundación Epistemonikos es una organización que busca acercar la información a quienes toman decisiones en salud, mediante el uso de tecnologías. Su principal desarrollo es la base de datos Epistemonikos (www.epistemonikos.org).
Los resúmenes de evidencia siguen un riguroso proceso de revisión por pares interno.
Declaración de conflictos de intereses
Los autores declaran no tener conflictos de intereses con la materia de este artículo.
Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.
Beta-blockade in patients undergoing noncardiac surgery has been widely recommended as a way to reduce cardiovascular adverse events during the perioperative period. However, studies have shown contradictory results. Searching in Epistemonikos database, which is maintained by screening multiple databases, we identified 22 systematic reviews comprising 131 studies addressing the question of this article, including 112 randomized trials. We combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded perioperative use of beta-blockers in patients undergoing noncardiac surgery, although probably decreases the risk of myocardial infarction, increases the risk of stroke and total mortality.
Autores:
Andrés Armstrong[1,2], Gabriel Rada[2,3,4,5,6], Fernando Altermatt[2,7]
Citación: Armstrong A, Rada G, Altermatt F. Is perioperative beta-blockade effective and safe in patients undergoing noncardiac surgery?. Medwave 2016; 16(Suppl5):e6819 doi: 10.5867/medwave.2016.6819
Fecha de publicación: 27/12/2016
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