***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Trials of beta blockers in patients undergoing non-cardiac surgery have reported conflicting results . This r and omised controlled trial , done in 190 hospitals in 23 countries , was design ed to investigate the effects of perioperative beta blockers . METHODS We r and omly assigned 8351 patients with , or at risk of , atherosclerotic disease who were undergoing non-cardiac surgery to receive extended-release metoprolol succinate ( n=4174 ) or placebo ( n=4177 ) , by a computerised r and omisation phone service . Study treatment was started 2 - 4 h before surgery and continued for 30 days . Patients , health-care providers , data collectors , and outcome adjudicators were masked to treatment allocation . The primary endpoint was a composite of cardiovascular death , non-fatal myocardial infa rct ion , and non-fatal cardiac arrest . Analyses were by intention to treat . This trial is registered with Clinical Trials.gov , number NCT00182039 . FINDINGS All 8351 patients were included in analyses ; 8331 ( 99.8 % ) patients completed the 30-day follow-up . Fewer patients in the metoprolol group than in the placebo group reached the primary endpoint ( 244 [ 5.8 % ] patients in the metoprolol group vs 290 [ 6.9 % ] in the placebo group ; hazard ratio 0.84 , 95 % CI 0.70 - 0.99 ; p=0.0399 ) . Fewer patients in the metoprolol group than in the placebo group had a myocardial infa rct ion ( 176 [ 4.2 % ] vs 239 [ 5.7 % ] patients ; 0.73 , 0.60 - 0.89 ; p=0.0017 ) . However , there were more deaths in the metoprolol group than in the placebo group ( 129 [ 3.1 % ] vs 97 [ 2.3 % ] patients ; 1.33 , 1.03 - 1.74 ; p=0.0317 ) . More patients in the metoprolol group than in the placebo group had a stroke ( 41 [ 1.0 % ] vs 19 [ 0.5 % ] patients ; 2.17 , 1.26 - 3.74 ; p=0.0053 ) . INTERPRETATION Our results highlight the risk in assuming a perioperative beta-blocker regimen has benefit without substantial harm , and the importance and need for large r and omised trials in the perioperative setting . Patients are unlikely to accept the risks associated with perioperative extended-release metoprolol BACKGROUND This post hoc analysis aim ed to determine whether neuraxial block was associated with a composite of cardiovascular death , non-fatal myocardial infa rct ion ( MI ) and non-fatal cardiac arrest within 30 days of r and omization in POISE trial patients . METHODS A total of 8351 non-cardiac surgical patients at high risk of cardiovascular complications were r and omized  to β-blocker or placebo . Neuraxial block was defined as spinal , lumbar or thoracic epidural anaesthesia . Logistic regression , with weighting using estimated propensity scores , was used to determine the association between neuraxial block and primary and secondary outcomes . RESULTS Neuraxial block was associated with an increased risk of the primary outcome [ 287 ( 7.3 % ) vs 229 ( 5.7 % ) ; odds ratio ( OR ) , 1.24 ; 95 % confidence interval ( CI ) , 1.02 - 1.49 ; P=0.03 ] and MI [ 230 ( 5.9 % ) vs 177 ( 4.4 % ) ; OR , 1.32 ; 95 % CI , 1.07 - 1.64 ; P=0.009 ] but not stroke [ 23 ( 0.6 % ) vs 32 ( 0.8 % ) ; OR , 0.76 ; 95 % CI , 0.44 - 1.33 ; P=0.34 ] , death [ 96 ( 2.5 % ) vs 111 ( 2.8 % ) ; OR , 0.87 ; 95 % CI , 0.65 - 1.17 ; P=0.37 ] or clinical ly significant hypotension [ 522 ( 13.4 % ) vs 484 ( 12.1 % ) ; OR , 1.13 ; 95 % CI , 0.99 - 1.30 ; P=0.08 ] . Thoracic epidural with general anaesthesia was associated with a worse primary outcome than general anaesthesia alone [ 86 ( 12.1 % ) vs 119 ( 5.4 % ) ; OR , 2.95 ; 95 % CI , 2.00 - 4.35 ; P<0.001 ] . CONCLUSIONS In patients at high risk of cardiovascular morbidity , neuraxial block was associated with an increased risk of adverse cardiovascular outcomes , which could be causal or because of residual confounding AIM To assess the long-term cardioprotective effect of bisoprolol in a r and omized high-risk population after successful major vascular surgery . High-risk patients were defined by the presence of one or more cardiac risk factor(s ) and a dobutamine echocardiography test positive for ischaemia . METHODS 1351 patients were screened prior to surgery , 846 patients had one or more risk factor(s ) , and 173 of these patients also had ischaemia during dobutamine echocardiography . One hundred and twelve patients could be r and omized for additional bisoprolol therapy or st and ard care . Eleven patients died in the peri-operative period ( up to 1 month after surgery ) . R and omized patients continued bisoprolol or st and ard care after surgery . During follow-up of 101 survivors ( median 22 months , range 11 - 30 ) cardiac death or myocardial infa rct ion was noted . No patient was lost during follow-up . Results The incidence of cardiac events during follow-up in the bisoprolol group was 12 % vs 32 % in the st and ard care group ( P=0.025 ) . Cardiac death occurred in 15 patients , nine patients in the st and ard care and in six in the bisoprolol group ; myocardial infa rct ion occurred in six patients , five in the st and ard care and one in the bisoprolol group . The odds ratio for cardiac death or myocardial infa rct ion after surgery in high-risk patients with additional bisoprolol therapy was 0.30 ( 0.11 - 0.83 ) . CONCLUSIONS Bisoprolol significantly reduced long-term cardiac death and myocardial infa rct ion in high-risk patients after successful major cardiac vascular surgery BACKGROUND We sought to assess the intra- and postoperative haemodynamic effects of continuous perioperative beta-adrenergic blockade combined with phosphodiesterase ( PDE ) III inhibition and its potential benefits in limiting perioperative myocardial ischaemia in high-risk vascular surgery patients . METHODS Seventy-five patients were r and omly assigned to receive tight heart rate ( HR ) control by a continuous infusion of : esmolol in combination with the PDE III inhibitor enoximone ( esmolol+enoximone group ) , esmolol infusion alone ( esmolol group ) , or st and ard therapy ( control group ) for a period of 48 h. Myocardial ischaemia and dysfunction were detected by serial plasma Troponin T ( TnT ) and B-type natriuretic peptide ( BNP ) measurements . RESULTS Cardiac index ( CI ) increased significantly only in esmolol+enoximone-treated patients [ CI : from 2.4 ( 0.2 ) litre min(-1 ) m(-2 ) at baseline to 3.2 ( 0.2 ) litre min(-1 ) m(-2 ) at 24 h after surgery ; P=0.001 ] and was significantly higher than in the esmolol [ CI : from 2.5 ( 0.2 ) litre min(-1 ) m(-2 ) at baseline to 2.6 ( 0.2 ) litre min(-1 ) m(-2 ) at 24 h ; P=0.18 ] and the control groups [ CI : from 2.4 ( 0.2 ) litre min(-1 ) m(-2 ) at baseline to 2.7 ( 0.2 ) litre min(-1 ) m(-2 ) at 24 h ; P=0.13 ] . A significant postoperative release of TnT was detected only in control patients . Plasma BNP levels increased towards the end of surgery in all patients . Peak plasma BNP concentrations were significantly higher in control patients [ 293 ( 98 ) pg ml(-1 ) ] than in esmolol [ 118 ( 71 ) pg ml(-1 ) ] and in esmolol+enoximone-treated patients [ 78 ( 21 ) pg ml(-1 ) ] . CONCLUSIONS Inotropic therapy with the PDE III inhibitor enoximone combined with tight HR control by a continuous infusion of esmolol improved cardiac function and reduced myocardial ischaemia in high-risk vascular surgery patients . CLINICAL TRIAL REGISTRATION INFORMATION-URL : http://www . clinical trials.gov . Unique identifier : NCT00348101 OBJECTIVES The aim of this study was to determine the long-term prognosis with postoperative markers of myocardial ischemia and infa rct ion . BACKGROUND Cardiac troponins ( cTn ) are superior to creatine kinase-MB fraction ( CK-MB ) in detecting perioperative myocardial infa rct ion ( PMI ) . However , their threshold levels signifying PMI and their long-term prognostic value are not yet determined . METHODS A cohort of 447 consecutive patients who underwent 501 major vascular procedures was prospect ively studied . Perioperative continuous 12-lead electrocardiogram monitoring , cardiac troponin-I ( cTn-I ) and /or cardiac troponin-T ( cTn-T ) , and CK-MB levels on the first three postoperative days , and long-term survival were determined . The association of different cutoff levels of CK-MB , troponin , and ischemia duration with long-term survival was investigated . RESULTS Between 14 ( 2.9 % ) and 107 ( 23.9 % ) of the patients sustained PMI , depending on the biochemical criteria used . Elevated postoperative CK-MB , cTn , and prolonged ( > 30 min ) ischemia , at all cutoff levels examined , predicted long-term mortality independent of the preoperative predictors : patient 's age , type of vascular surgery , previous myocardial infa rct ion , and renal failure ( Cox multivariate analysis ) . Both CK-MB > 10 % and cTn-I > 1.5 ng/ml and /or cTn-T > 0.1 ng/ml independently predicted a 3.75-fold and 2.06-fold increase in long-term mortality ( p = 0.006 and 0.012 , respectively ) . Similarly , both CK-MB > 5 % and cTn-I > 0.6 ng/ml and /or cTn-T > 0.03 ng/ml independently predicted a 2.15-fold and 1.89-fold increase in mortality ( p = 0.018 and 0.01 , respectively ) . Patients with both these markers elevated had a 4.19-fold increase in mortality ( p < 0.001 ) . CONCLUSIONS Postoperative CK-MB and troponin , even at low cutoff levels , are independent and complementary predictors of long-term mortality after major vascular surgery OBJECTIVES This article describes the rationale and design of the DECREASE-XIII trial , which aims to evaluate the potential of esmolol infusion , an ultra-short-acting beta-blocker , during surgery as an add-on to chronic low-dose beta-blocker therapy to maintain perioperative haemodynamic stability during major vascular surgery . DESIGN A double-blind , placebo-controlled , r and omised trial . MATERIAL S & METHODS A total of 260 vascular surgery patients will be r and omised to esmolol or placebo  as an add-on to st and ard medical care , including chronic low-dose beta-blockers . Esmolol is titrated to maintain a heart rate within a target window of 60 - 80 beats per minute for 24 h from the induction of anaesthesia . Heart rate and ischaemia are assessed by continuous 12-lead electrocardiographic monitoring for 72 h , starting 1 day prior to surgery . The primary outcome measure is duration of heart rate outside the target window during infusion of the study drug . Secondary outcome measures will be the efficacy parameters of occurrence of cardiac ischaemia , troponin T release , myocardial infa rct ion and cardiac death within 30 days after surgery and safety parameters such as the occurrence of stroke and hypotension . CONCLUSIONS This study will provide data on the efficacy of esmolol titration in chronic beta-blocker users for tight heart-rate control and reduction of ischaemia in patients undergoing vasc 
    Output:
    
This meta- analysis currently offers no clear evidence that perioperative beta-adrenergic blockade reduces postoperative cardiac morbidity and mortality in people undergoing major non-cardiac vascular surgery .