The Effect of Steroids in Patients Undergoing Cardiopulmonary Bypass: An Individual Patient Meta-Analysis of Two Randomized Trials

Richard P Whitlock; Jan M Dieleman; Emilie Belley-Cote; Jessica Vincent; Michelle Zhang; P J Devereaux; Cor J Kalkman; Diederik van Dijk; Salim Yusuf

doi:10.1053/j.jvca.2019.06.012

The Effect of Steroids in Patients Undergoing Cardiopulmonary Bypass: An Individual Patient Meta-Analysis of Two Randomized Trials

J Cardiothorac Vasc Anesth. 2020 Jan;34(1):99-105. doi: 10.1053/j.jvca.2019.06.012. Epub 2019 Jun 20.

Authors

Richard P Whitlock¹, Jan M Dieleman², Emilie Belley-Cote³, Jessica Vincent⁴, Michelle Zhang⁴, P J Devereaux⁵, Cor J Kalkman², Diederik van Dijk², Salim Yusuf³

Affiliations

¹ Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. Electronic address: richard.whitlock@phri.ca.
² University Medical Center, Utrecht, Netherlands.
³ Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
⁴ Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.
⁵ Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

PMID: 31401207
DOI: 10.1053/j.jvca.2019.06.012

Abstract

Objective: Steroids suppress the inflammatory response to cardiopulmonary bypass, but the impact on death at 30 days, myocardial infarction or injury, stroke, renal failure, respiratory failure, new atrial fibrillation, transfusion requirement, infection, and length of intensive care unit (ICU) and hospital stays are uncertain.

Design: Patient-level data meta-analysis of 2 randomized trials.

Setting: Eighty-eight cardiac surgical centers in 19 countries.

Participants: A total of 11,989 participants, from the Steroids in Cardiac Surgery trial and the Dexamethasone in Cardiac Surgery study, undergoing cardiac surgery with the use of cardiopulmonary bypass.

Interventions: Participants were randomly assigned to steroid or placebo.

Measures and main results: Outcomes assessed were mortality at 30 days, myocardial infarction or injury, stroke, renal failure, respiratory failure, new atrial fibrillation, transfusion requirement, infection, and length of ICU and hospital stays. There was no significant difference in death at 30 days between the steroid and placebo groups (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.72-1.07). Myocardial infarction did not differ significantly (OR, 1.17; 95% CI, 0.93-1.47); however, myocardial injury was higher in the steroid group (OR, 1.25; 95% CI, 1.12-1.40). There were no significant differences for the outcomes of stroke, renal failure, new atrial fibrillation, or transfusion. Steroids significantly reduced respiratory failure (OR, 0.83; 95% CI, 0.75-0.99), infection (OR, 0.80; 95% CI, 0.72-0.89), and length of ICU (p < 0.001) and hospital stays (p = 0.006).

Conclusions: This patient-level meta-analysis does not support the routine use of steroids in cardiac surgery. Steroid administration did not decrease the risk of death, myocardial infarction, stroke, renal failure, new atrial fibrillation, or transfusion. Steroids increased the risk of myocardial injury in both the Steroids in Cardiac Surgery and Dexamethasone in Cardiac Surgery trials. Finally, steroids lowered the risk of respiratory failure and infection, and reduced length of ICU and hospital stay.

Keywords: cardiac surgery; cardiopulmonary bypass; inflammation; steroid.

Publication types

Meta-Analysis

MeSH terms

Cardiac Surgical Procedures* / adverse effects
Cardiopulmonary Bypass / adverse effects
Humans
Myocardial Infarction*
Postoperative Complications / prevention & control
Randomized Controlled Trials as Topic
Steroids

Substances

Steroids