High-dose corticosteroids in heart surgery

During heart surgery, high doses of corticosteroids aiming to reduce inflammation are often administered. This practice, however, is controversial since there is no evidence available to show clear benefits. Moreover, corticosteroids have the potential of important side-effects. The aim of this meta-analysis was to summarize (pool) data from studies on this subject and to estimate the effect of corticosteroid administration on the risk of major complications (death, heart infarction, lung problems) following heart surgery.

Major databases of medical literature were searched for publications of studies that randomly assigned adult patient undergoing heart surgery to receive either corticosteroid treatment compared to no treatment or placebo. A total of 54 publications were selected for the analysis. The quality of most of these publications was rather poor, thereby limiting the value of the pooled risk estimate. For none of the major complications (death, heart infarction, lung problems), a change of risk by corticosteroid administration could be demonstrated. Only the risk of (often encountered) heart rhythm disturbances (atrial fibrillation) was clearly shown to be reduced (around 40% less).

The authors therefore conclude that no beneficial effects of high-dose corticosteroids could be shown on the risk of major complications following heart surgery, although this conclusion is limited to low quality of the data available. For a more definitive conclusion, studies with much larger numbers of patients need to be performed.

Authors' conclusions: 

This meta-analysis showed no beneficial effect of corticosteroid use on mortality, cardiac and pulmonary complications in cardiac surgery patients.

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Background: 

High-dose prophylactic corticosteroids are often administered during cardiac surgery. Their use, however, remains controversial, as no trials are available that have been sufficiently powered to draw conclusions on their effect on major clinical outcomes.

Objectives: 

The objective of this meta-analysis was to estimate the effect of prophylactic corticosteroids in cardiac surgery on mortality, cardiac and pulmonary complications.

Search strategy: 

Major medical databases (CENTRAL, MEDLINE, EMBASE, CINAHL and Web of Science) were systematically searched for randomised studies assessing the effect of corticosteroids in adult cardiac surgery. Database were searched for the full period covered, up to December 2009. No language restrictions were applied.

Selection criteria: 

Randomised controlled trials comparing corticosteroid treatment to either placebo treatment or no treatment in adult cardiac surgery were selected. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more end-points.

Data collection and analysis: 

The processes of searching and selection for inclusion eligibility were performed independently by two authors. Also, quality assessment and data-extraction of selected studies were independently performed by two authors. The primary endpoints were mortality, cardiac and pulmonary complications. The main effect measure was the Peto odds ratio comparing corticosteroids to no treatment/placebo.

Main results: 

Fifty-four randomised studies, mostly of limited quality, were included. Altogether, 3615 patients were included in these studies. The pooled odds ratio for mortality was 1.12 (95% CI 0.65 to 1.92), showing no mortality reduction in patients treated with corticosteroids. The odds ratios for myocardial and pulmonary complications were 0.95, (95% CI 0.57 to 1.60) and 0.83 (95% CI 0.49 to 1.40), respectively. The use of a random effects model did not substantially influence study results. Analyses of secondary endpoints showed a reduction of atrial fibrillation and an increase in gastrointestinal bleeding in the corticosteroids group.

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