Duncan Et Al-2018-Cochrane Database of Systematic Reviews

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Cochrane Database of Systematic Reviews
Alpha-2 adrenergic agonists for the prevention of cardiac

complications among adults undergoing surgery (Review)
Duncan D, Sankar A, Beattie WS, Wijeysundera DN
Duncan D, Sankar A, Beattie WS, Wijeysundera DN.

Alpha-2 adrenergic agonists for the prevention of cardiac complications among adults undergoing surgery.
Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD004126.
DOI: 10.1002/14651858.CD004126.pub3.
www.cochranelibrary.com
Alpha-2 adrenergic agonists for the prevention of cardiac complications among adults undergoing surgery
(Review)
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
TABLE OF CONTENTS
HEADER......................................................................................................................................................................................................... 1
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 4
BACKGROUND.............................................................................................................................................................................................. 8
OBJECTIVES.................................................................................................................................................................................................. 8
METHODS..................................................................................................................................................................................................... 8
RESULTS........................................................................................................................................................................................................ 11
Figure 1.................................................................................................................................................................................................. 12
Figure 2.................................................................................................................................................................................................. 14
Figure 3.................................................................................................................................................................................................. 15
Figure 4.................................................................................................................................................................................................. 20
Figure 5.................................................................................................................................................................................................. 21
DISCUSSION.................................................................................................................................................................................................. 21
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 23
ACKNOWLEDGEMENTS................................................................................................................................................................................ 24
REFERENCES................................................................................................................................................................................................ 25
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 48
DATA AND ANALYSES.................................................................................................................................................................................... 108
Analysis 1.1. Comparison 1 Alpha-2 adrenergic agonists versus control in non-cardiac surgery, Outcome 1 All-cause mortality..... 109
Analysis 1.2. Comparison 1 Alpha-2 adrenergic agonists versus control in non-cardiac surgery, Outcome 2 Cardiac mortality...... 109
Analysis 1.3. Comparison 1 Alpha-2 adrenergic agonists versus control in non-cardiac surgery, Outcome 3 Myocardial 110
infarction................................................................................................................................................................................................
Analysis 1.4. Comparison 1 Alpha-2 adrenergic agonists versus control in non-cardiac surgery, Outcome 4 Myocardial 110
ischaemia...............................................................................................................................................................................................
Analysis 1.5. Comparison 1 Alpha-2 adrenergic agonists versus control in non-cardiac surgery, Outcome 5 Supraventricular 111
tachyarrhythmia....................................................................................................................................................................................
Analysis 1.6. Comparison 1 Alpha-2 adrenergic agonists versus control in non-cardiac surgery, Outcome 6 Heart failure............ 111
Analysis 1.7. Comparison 1 Alpha-2 adrenergic agonists versus control in non-cardiac surgery, Outcome 7 Acute stroke............ 112
Analysis 1.8. Comparison 1 Alpha-2 adrenergic agonists versus control in non-cardiac surgery, Outcome 8 Bradycardia............. 112
Analysis 1.9. Comparison 1 Alpha-2 adrenergic agonists versus control in non-cardiac surgery, Outcome 9 Hypotension........... 113
Analysis 2.1. Comparison 2 Alpha-2 adrenergic agonists versus control in cardiac surgery, Outcome 1 All-cause mortality......... 114
Analysis 2.2. Comparison 2 Alpha-2 adrenergic agonists versus control in cardiac surgery, Outcome 2 Myocardial infarction....... 114
Analysis 2.3. Comparison 2 Alpha-2 adrenergic agonists versus control in cardiac surgery, Outcome 3 Myocardial ischaemia...... 115
Analysis 2.4. Comparison 2 Alpha-2 adrenergic agonists versus control in cardiac surgery, Outcome 4 Supraventricular 115
tachyarrhythmia....................................................................................................................................................................................
Analysis 2.5. Comparison 2 Alpha-2 adrenergic agonists versus control in cardiac surgery, Outcome 5 Heart failure.................... 116
Analysis 2.6. Comparison 2 Alpha-2 adrenergic agonists versus control in cardiac surgery, Outcome 6 Acute stroke.................... 116
Analysis 2.7. Comparison 2 Alpha-2 adrenergic agonists versus control in cardiac surgery, Outcome 7 Bradycardia.................... 116
Analysis 2.8. Comparison 2 Alpha-2 adrenergic agonists versus control in cardiac surgery, Outcome 8 Hypotension................... 117
Analysis 3.1. Comparison 3 Alpha-2 adrenergic agonists versus control in non-cardiac surgery - stratified by vascular versus 118
non-vascular surgery, Outcome 1 All-cause mortality........................................................................................................................
non-vascular surgery, Outcome 2 Cardiac mortality..........................................................................................................................
non-vascular surgery, Outcome 3 Myocardial infarction....................................................................................................................
non-vascular surgery, Outcome 4 Myocardial ischaemia...................................................................................................................
Analysis 4.1. Comparison 4 Alpha-2 adrenergic agonists (stratified by drug) versus control in non-cardiac surgery, Outcome 1 121
All-cause mortality................................................................................................................................................................................
Cardiac mortality...................................................................................................................................................................................
Alpha-2 adrenergic agonists for the prevention of cardiac complications among adults undergoing surgery (Review) i
Informed decisions.
Myocardial infarction............................................................................................................................................................................
Hypotension..........................................................................................................................................................................................
Analysis 5.1. Comparison 5 Alpha-2 adrenergic agonists versus control in non-cardiac surgery studies with blinding and 125
concealed allocation, Outcome 1 All-cause mortality........................................................................................................................
concealed allocation, Outcome 2 Myocardial infarction....................................................................................................................
concealed allocation, Outcome 3 Myocardial ischaemia...................................................................................................................
Analysis 6.1. Comparison 6 Alpha-2 adrenergic agonists versus control in studies that used strict definitions of myocardial 126
infarction or ischaemia, Outcome 1 Myocardial infarction................................................................................................................
Analysis 6.2. Comparison 6 Alpha-2 adrenergic agonists versus control in studies that used strict definitions of myocardial 127
infarction or ischaemia, Outcome 2 Myocardial ischaemia...............................................................................................................
Analysis 7.1. Comparison 7 Alpha-2 adrenergic agonists versus control in non-cardiac surgery (excluding Oliver 1999 and 128
Devereaux 2014), Outcome 1 All-cause mortality...............................................................................................................................
Devereaux 2014), Outcome 2 Cardiac mortality.................................................................................................................................
Devereaux 2014), Outcome 3 Myocardial infarction...........................................................................................................................
Analysis 8.1. Comparison 8 Alpha-2 adrenergic agonists (excluding mivazerol) versus control in non-cardiac surgery, Outcome 130
1 All-cause mortality.............................................................................................................................................................................
2 Cardiac mortality................................................................................................................................................................................
3 Myocardial infarction.........................................................................................................................................................................
4 Myocardial ischaemia........................................................................................................................................................................
5 Supraventricular tachyarrhythmia....................................................................................................................................................
6 Heart failure........................................................................................................................................................................................
7 Acute stroke........................................................................................................................................................................................
8 Bradycardia.........................................................................................................................................................................................
9 Hypotension.......................................................................................................................................................................................
Analysis 9.1. Comparison 9 Alpha-2 adrenergic agonists versus control in non-cardiac surgery within past 20 years, Outcome 134
1 All-cause mortality.............................................................................................................................................................................
2 Cardiac mortality................................................................................................................................................................................
3 Myocardial infarction.........................................................................................................................................................................
4 Myocardial ischaemia........................................................................................................................................................................
5 Heart failure........................................................................................................................................................................................
6 Acute stroke........................................................................................................................................................................................
Analysis 10.1. Comparison 10 Alpha-2 adrenergic agonists versus control in cardiac surgery within past 20 years, Outcome 1 137
All-cause mortality................................................................................................................................................................................
Myocardial infarction............................................................................................................................................................................
Myocardial ischaemia...........................................................................................................................................................................
Alpha-2 adrenergic agonists for the prevention of cardiac complications among adults undergoing surgery (Review) ii
Informed decisions.
Supraventricular tachyarrhythmia.......................................................................................................................................................
Heart failure...........................................................................................................................................................................................
Acute stroke...........................................................................................................................................................................................
APPENDICES................................................................................................................................................................................................. 140
FEEDBACK..................................................................................................................................................................................................... 142
WHAT'S NEW................................................................................................................................................................................................. 143
HISTORY........................................................................................................................................................................................................ 143
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 144
DECLARATIONS OF INTEREST..................................................................................................................................................................... 144
SOURCES OF SUPPORT............................................................................................................................................................................... 145
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 145
NOTES........................................................................................................................................................................................................... 145
INDEX TERMS............................................................................................................................................................................................... 146
Alpha-2 adrenergic agonists for the prevention of cardiac complications among adults undergoing surgery (Review) iii
Informed decisions.
[Intervention Review]
Alpha-2 adrenergic agonists for the prevention of cardiac complications

among adults undergoing surgery
Dallas Duncan1, Ashwin Sankar1, W Scott Beattie2, Duminda N Wijeysundera3
1Department of Anesthesia, University of Toronto, Toronto, Canada. 2Department of Anaesthesia, Toronto General Hospital, University
Health Network, Toronto, Canada. 3Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
Contact address: Duminda N Wijeysundera, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario,
M5B 1W8, Canada. [email protected], [email protected].
Editorial group: Cochrane Anaesthesia Group.

Publication status and date: Edited (no change to conclusions), comment added to review, published in Issue 9, 2018.
Citation: Duncan D, Sankar A, Beattie WS, Wijeysundera DN. Alpha-2 adrenergic agonists for the prevention of cardiac
complications among adults undergoing surgery. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD004126. DOI:
10.1002/14651858.CD004126.pub3.
ABSTRACT
Background
The surgical stress response plays an important role on the pathogenesis of perioperative cardiac complications. Alpha-2 adrenergic
agonists attenuate this response and may help prevent postoperative cardiac complications.
Objectives
To determine the efficacy and safety of α-2 adrenergic agonists for reducing mortality and cardiac complications in adults undergoing
cardiac surgery and non-cardiac surgery.
Search methods
We searched CENTRAL (2017, Issue 4), MEDLINE (1950 to April Week 4, 2017), Embase (1980 to May 2017), the Science Citation Index, clinical
trial registries, and reference lists of included articles.
Selection criteria
We included randomized controlled trials that compared α-2 adrenergic agonists (i.e. clonidine, dexmedetomidine or mivazerol) against
placebo or non-α-2 adrenergic agonists. Included trials had to evaluate the efficacy and safety of α-2 adrenergic agonists for preventing
perioperative mortality or cardiac complications (or both), or measure one or more relevant outcomes (i.e. death, myocardial infarction,
heart failure, acute stroke, supraventricular tachyarrhythmia and myocardial ischaemia).
Data collection and analysis

Two authors independently assessed trial quality, extracted data and independently performed computer entry of abstracted data. We
contacted study authors for additional information. Adverse event data were gathered from the trials. We evaluated included studies using
the Cochrane 'Risk of bias' tool, and the quality of the evidence underlying pooled treatment effects using GRADE methodology. Given the
clinical heterogeneity between cardiac and non-cardiac surgery, we analysed these subgroups separately. We expressed treatment effects
as pooled risk ratios (RR) with 95% confidence intervals (CI).
Main results
We included 47 trials with 17,039 participants. Of these studies, 24 trials only included participants undergoing cardiac surgery, 23
only included participants undergoing non-cardiac surgery and eight only included participants undergoing vascular surgery. The α-2
adrenergic agonist studied was clonidine in 21 trials, dexmedetomidine in 24 trials and mivazerol in two trials.
Alpha-2 adrenergic agonists for the prevention of cardiac complications among adults undergoing surgery (Review) 1
Informed decisions.
In non-cardiac surgery, there was high quality evidence that α-2 adrenergic agonists led to a similar risk of all-cause mortality compared
with control groups (1.3% with α-2 adrenergic agonists versus 1.7% with control; RR 0.80, 95% CI 0.61 to 1.04; participants = 14,081; studies
= 16). Additionally, the risk of cardiac mortality was similar between treatment groups (0.8% with α-2 adrenergic agonists versus 1.0% with
control; RR 0.86, 95% CI 0.60 to 1.23; participants = 12,525; studies = 5, high quality evidence). The risk of myocardial infarction was probably
similar between treatment groups (RR 0.94, 95% CI 0.69 to 1.27; participants = 13,907; studies = 12, moderate quality evidence). There was
no associated effect on the risk of stroke (RR 0.93, 95% CI 0.55 to 1.56; participants = 11,542; studies = 7; high quality evidence). Conversely,
α-2 adrenergic agonists probably increase the risks of clinically significant bradycardia (RR 1.59, 95% CI 1.18 to 2.13; participants = 14,035;
studies = 16) and hypotension (RR 1.24, 95% CI 1.03 to 1.48; participants = 13,738; studies = 15), based on moderate quality evidence.
There was insufficient evidence to determine the effect of α-2 adrenergic agonists on all-cause mortality in cardiac surgery (RR 0.52, 95%
CI 0.26 to 1.04; participants = 1947; studies = 16) and myocardial infarction (RR 1.01, 95% CI 0.43 to 2.40; participants = 782; studies = 8),
based on moderate quality evidence. There was one cardiac death in the clonidine arm of a study of 22 participants. Based on very limited
data, α-2 adrenergic agonists may have reduced the risk of stroke (RR 0.37, 95% CI 0.15 to 0.93; participants = 1175; studies = 7; outcome
events = 18; low quality evidence). Conversely, α-2 adrenergic agonists increased the risk of bradycardia from 6.4% to 12.0% (RR 1.88, 95%
CI 1.35 to 2.62; participants = 1477; studies = 10; moderate quality evidence), but their effect on hypotension was uncertain (RR 1.19, 95%
CI 0.87 to 1.64; participants = 1413; studies = 9; low quality evidence).
These results were qualitatively unchanged in subgroup analyses and sensitivity analyses.
Authors' conclusions
Our review concludes that prophylactic α-2 adrenergic agonists generally do not prevent perioperative death or major cardiac
complications. For non-cardiac surgery, there is moderate-to-high quality evidence that these agents do not prevent death, myocardial
infarction or stroke. Conversely, there is moderate quality evidence that these agents have important adverse effects, namely increased
risks of hypotension and bradycardia. For cardiac surgery, there is moderate quality evidence that α-2 adrenergic agonists have no effect
on the risk of mortality or myocardial infarction, and that they increase the risk of bradycardia. The quality of evidence was inadequate to
draw conclusions regarding the effects of alpha-2 agonists on stroke or hypotension during cardiac surgery.
PLAIN LANGUAGE SUMMARY
Using alpha-2 adrenergic agonists to prevent heart complications after major surgery
Review question
Do alpha-2 adrenergic agonists (clonidine, dexmedetomidine and mivazerol) reduce the number of deaths and heart complications when
given around the time of surgery?
Background
Heart-related complications can lead to death and long hospital stays after surgery. Each year, about 300 million people undergo major
surgery, of whom nine million experience serious heart complications. These complications may occur, in part, because surgery places a
large stress on the heart. This stress can lead to high blood pressure and high heart rates during surgery, neither of which are good for
the heart. Alpha-2 adrenergic agonists are a group of medicines that can prevent the blood pressure and heart rate from increasing during
surgery. Thus, these medicines may also protect the heart from the stress of surgery. We wanted to find out if giving these medicines around
the time of surgery could protect the heart from the stress of surgery and thus prevent major heart complications.
Study characteristics
We found 47 studies that were published up to May 2017. These studies involved 17,039 adults who had major surgery. Twenty-four studies
involved 2672 adults having heart surgery. Twenty-three studies involved 14,367 adults undergoing major operations other than heart
surgery. Forty studies compared alpha-2 adrenergic agonists to dummy treatment (placebo). The other seven studies compared them to
other medicines. Twenty-one studies tested an alpha-2 adrenergic agonist medicine called clonidine, 24 studied another medicine called
dexmedetomidine and two studied another medicine called mivazerol. The duration of alpha-2 adrenergic agonist medicine studied varied
from one dose before surgery to three days of treatment. Most people who took part in these studies were men, and their average age was
60 to 70 years old. Fourteen studies reported receiving money from the company that manufactured the medicine being tested in the same
study. Another 15 studies did not report where they received the money needed to fund the study. The number of people who took part in
each study varied between 20 participants to as many as 10,000 participants. Nineteen studies included more than 100 participants.
Key results
We found that alpha-2 adrenergic agonists generally had no clear benefits for preventing death or major complications after surgery. For
people having major operations other than heart surgery, alpha-2 adrenergic agonists did not lower their chances of dying, having a heart
attack or having a stroke after surgery. We did not find sufficient evidence that, in people having heart surgery, alpha-2 adrenergic lowered
the risk of dying or having a heart attack after surgery. There was some very limited evidence that these medicines might prevent strokes
after heart surgery. Nonetheless, more research is needed before we can be certain that alpha-2 adrenergic agonists truly have this benefit.
Informed decisions.
These medicines also had some important side effects. People who received alpha-2 adrenergic agonists were much more likely to have
low blood pressures or low heart rates during or after surgery.
Quality of evidence
We assessed the quality of all studies we identified using a specialized tool called the GRADE criteria. In general, we found that most of the
evidence in these studies was moderate or high quality. Thus, based on our results, we can be reasonably certain that alpha-2 adrenergic
agonists are not helpful for reducing the numbers of deaths or major heart complications that happen after surgery.
Alpha-2 adrenergic agonists for the prevention of cardiac complications among adults undergoing surgery (Review)
SUMMARY OF FINDINGS
Summary of findings for the main comparison. Alpha-2 adrenergic agonists compared to control in non-cardiac surgery
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Alpha-2 adrenergic agonists compared to control in non-cardiac surgery
Patient or population: adults undergoing non-cardiac surgery

Setting: hospital inpatient care
Intervention: α-2 adrenergic agonist
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Comparison: placebo or inactive control
Outcomes Anticipated absolute effects* (95% CI) Risk ratio № of partici- Quality of the Comments
(95% CI) pants evidence
Risk with con- Risk with α-2 adren- (studies) (GRADE)
trol ergic agonists
All-cause mortality Study population RR 0.80 14,081 ⊕⊕⊕⊕ -

(0.61 to 1.04) (16 RCTs) High1,2
(within 30-days after surgery: any reported death) 17 per 1000 13 per 1000
(10 to 17)
Cardiac mortality Study population RR 0.86 12,525 ⊕⊕⊕⊕ -

(0.60 to 1.23) (5 RCTs) High1,2
(within 30-days after surgery: sudden death or 10 per 1000 8 per 1000
death resulting from a primarily identifiable car- (6 to 12)
diac cause.)
Myocardial infarction Study population RR 0.94 13,907 ⊕⊕⊕⊝ -

(0.69 to 1.27) (12 RCTs) Moderate1,2,3
(within 30-days after surgery: as detected on an 59 per 1000 55 per 1000
electrocardiogram or trans-oesophageal echocar- (41 to 75)
diogram)

Acute stroke Study population RR 0.93 11,542 ⊕⊕⊕⊕ -
(0.55 to 1.56) (7 RCTs) High1
(within 30-days after surgery: new focal neurolog- 5 per 1000 4 per 1000
ic deficit with signs and symptoms lasting longer (3 to 8)
than 24 hours)
Bradycardia Study population RR 1.59 14,035 ⊕⊕⊕⊝ -

(1.18 to 2.13) (16 RCTs) Moderate1,2,4
(requiring pharmacological or pacemaker treat- 75 per 1000 119 per 1000
ment during the period of study drug administra- (89 to 160)
tion)
4
Hypotension Study population RR 1.24 13,738 ⊕⊕⊕⊝ -
(1.03 to 1.48) (15 RCTs) Moderate1,2,4
(requiring treatment with inotropes or vasopres- 304 per 1000 377 per 1000
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sors during the period of study drug administra- (313 to 450)
tion)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and
its 95% CI).
CI: confidence interval; RCT: randomized controlled trial; RR: risk ratio.
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Trusted evidence.
GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is sub-
stantially different.
Low quality: Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.
1Risk of bias was not serious. Although multiple studies lacked proper allocation concealment and blinding, outcome unlikely to be influenced. Not downgraded.
2Indirectness not serious. Intervention (mivazerol) used in one large study not available for clinical use. Not downgraded.
3Evidence of publication bias in funnel plot of analysis. Downgraded by one level.
4Serious inconsistency between studies indicated by substantial heterogeneity. Downgraded by one level.
Summary of findings 2. Alpha-2 adrenergic agonists compared to control in cardiac surgery
Alpha-2 adrenergic agonists compared to control in cardiac surgery
Patient or population: adults undergoing cardiac surgery

Setting: hospital inpatient care
Intervention: α-2 adrenergic agonist
Comparison: placebo or inactive control

Outcomes Anticipated absolute effects* (95% Relative effect № of partici- Quality of the Comments
CI) (95% CI) pants evidence
(studies) (GRADE)
Risk with con- Risk with α-2
trol adrenergic ago-
nists
All-cause mortality Study population RR 0.52 1947 ⊕⊕⊕⊝ -

(0.26 to 1.04) (16 RCTs) Moderate1,2
(within 30-days after surgery: any reported death) 21 per 1000 11 per 1000
(5 to 21)
5
Cardiac mortality 1 death from 12 participants in cloni- Not estimable 22 Not estimable We did not
dine arm, and no deaths in 10 partici- GRADE evi-
(within 30-days after surgery: sudden death or death pants in control arm. (1 RCT) dence for this
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resulting from a primarily identifiable cardiac cause) outcome as ac-
curate estima-
tion of RRs is
not possible for
such low event
rates.
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Trusted evidence.
Myocardial infarction Study population RR 1.01 782 ⊕⊕⊕⊝ -
(0.43 to 2.40) (8 RCTs) Moderate1,2
(within 30-days after surgery: sudden death or death 20 per 1000 21 per 1000
resulting from a primarily identifiable cardiac cause) (9 to 49)
Acute stroke Study population RR 0.37 1175 ⊕⊕⊝⊝ Total of 18

(0.15 to 0.93) (7 RCTs) Low1,3 acute stokes re-
(within 30-days after surgery: new focal neurologic 24 per 1000 9 per 1000 ported, with 14
deficit with signs and symptoms lasting longer than (4 to 22) in control group
24 hours) and 4 in treat-
ment group.
Bradycardia Study population RR 1.88 1477 ⊕⊕⊕⊝ -

(1.35 to 2.62) (10 RCTs) Moderate1,4
(requiring pharmacological or pacemaker treatment 64 per 1000 120 per 1000
during the period of study drug administration) (86 to 167)
Hypotension Study population RR 1.19 1413 ⊕⊕⊝⊝ -

(0.87 to 1.64) (9 RCTs) Low1,2,5
(requiring treatment with inotropes or vasopressors 332 per 1000 395 per 1000
during the period of study drug administration) (289 to 544)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and

its 95% CI).
CI: confidence interval; RCT: randomized controlled trial; RR: risk ratio.
GRADE Working Group grades of evidence

High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is sub-
stantially different.
Low quality: Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.
1Risk of bias was not serious. Although multiple studies lack proper allocation concealment and blinding, outcome unlikely to be influenced. Not downgraded.
6
2Serious imprecision, because analysis was below optimal information size and confidence interval includes significant benefit and harm. Downgraded by one level.
3Very serious imprecision, because analysis is below optimal information size and number of events was very small. Downgraded by two levels.
4Serious imprecision, because analysis was below optimal information size. Downgraded by one level
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5Serious inconsistency between studies indicated by substantial heterogeneity. Downgraded one level.
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7
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BACKGROUND Why it is important to do this review
Description of the condition Previous systematic reviews of perioperative α-2 adrenergic

agonists have been published (Biccard 2008; Nishina 2002; Stevens
Perioperative cardiac complications are a major health concern 2003). However, two of them were restricted to individual
for the 312 million people who annually undergo major α-2 adrenergic agonists, namely clonidine (Nishina 2002), and
surgery worldwide (Meara 2015). For example, about 3% of dexmedetomidine (Biccard 2008). The other review was restricted
people who undergo major non-cardiac surgery experience to studies published before 2002 (Stevens 2003). A systematic
perioperative myocardial infarction (MI) (VISION 2014). Major review according to the Cochrane methodology is therefore
cardiac complications, such as MI, lead to increased mortality, justified. The current review is an update to a previous Cochrane
hospital stay and costs (Fleischmann 2003; Force 1990; VISION Review that included studies published before August 2008
2014). The surgical stress response may play an important (Wijeysundera 2009). This update was deemed necessary, in part,
role in the pathogenesis of these complications. Specifically, given the publication of the largest RCT to-date of perioperative
surgical stress stimulates the sympathetic nervous system, which α-2 adrenergic agonists, the Perioperative Ischemic Evaluation - 2
in turns leads to increased plasma levels of norepinephrine (POISE-2) trial (Devereaux 2014a).
and epinephrine (Halter 1997). These effects increase blood
pressure and heart rate, which can predispose the myocardium to OBJECTIVES
ischaemia, especially in people with decreased coronary blood flow
reserve. To determine the efficacy and safety of α-2 adrenergic agonists for
reducing mortality and cardiac complications in adults undergoing
Description of the intervention cardiac surgery and non-cardiac surgery.
Alpha-2 (α-2) adrenergic agonists selectively bind to presynaptic METHODS
α-2 adrenergic receptors to activate a negative feedback
mechanism that inhibits central sympathetic outflow (Muzi 1992). Criteria for considering studies for this review
These receptors are mainly located in the central nervous system,
specifically in the brain stem and locus coeruleus. Activation Types of studies
of these receptors lead to hypotension, bradycardia, central We included published RCTs.
sedation, anxiolysis and analgesia. Three specific α-2 adrenergic
agonists that have been evaluated in people undergoing surgery, Types of participants
namely clonidine, dexmedetomidine and mivazerol. Clonidine
We included adults (aged 18 years or older) undergoing surgery
and dexmedetomidine are available for clinical use, while the
under general anaesthesia, neuraxial anaesthesia, or both. We
use of mivazerol has been restricted to clinical trials. Clonidine
excluded surgery performed under local anaesthesia or peripheral
has a half-life of 12 to 18 hours with excellent bioavailability,
nerve blockade alone because such procedures are generally
lending to its suitability for once daily administration in oral tablet
associated with a very low risk of mortality and morbidity. We
or transdermal patch forms. An intravenous (IV) formulation of
also excluded surgery performed on pregnant women, organ
clonidine is also available. Dexmedetomidine has a shorter half-life
transplant recipients, or people with substance withdrawal. Organ
of only two hours and variable bioavailability, consequently making
transplantation procedures may be associated with a high risk of
it more suited for administration as a continuous IV infusion (Flood
mortality unrelated to cardiovascular causes, thereby masking any
2015). Similarly, mivazerol is also administered as a continuous IV
potential benefit from α-2 adrenergic agonists.
infusion (Oliver 1999).
Types of interventions
How the intervention might work
The experimental intervention must have included clonidine,
As indicated above, α-2 adrenergic agonists inhibit central mivazerol or dexmedetomidine administration before surgery
sympathetic outflow. Hence, they can attenuate perioperative (within 24 hours), during surgery, or after surgery (within 48
haemodynamic abnormalities (Ellis 1994; McSPI-Europe 1997; hours). The medications must have been administered via
Talke 1995), and perhaps also prevent cardiac complications. IV, intramuscular, oral or transdermal routes. There were no
Furthermore, clonidine has the unique ability to reduce restrictions on the dose, duration or frequency of the intervention.
sympathetic activity without blunting the baroreflex, which
is critical for responding to the fluctuations in circulating We permitted active interventions in the comparator group only
blood volume often encountered during surgery (Muzi 1992). if the comparator was judged to have minimal to no effect on
Nonetheless, α-2 adrenergic agonists have important adverse the primary or secondary outcomes. For example, in a trial where
effects, including hypotension and bradycardia (Biccard 2008). dexmedetomidine was being primarily evaluated for the role of
These haemodynamic effects may have clinically important providing postoperative sedation after major surgery, comparison
consequences for people undergoing surgery. For example, in to propofol was judged to be reasonable.
the Perioperative Ischemic Evaluation - 1 (POISE-1) randomized
controlled trial (RCT), acute perioperative β-blockade increased Types of outcome measures
risks of bradycardia, hypotension, acute stroke, and death (POISE
Included trials had to evaluate the efficacy or safety of α-2
2008). Given that α-2 adrenergic agonists have both potential
adrenergic agonists in reducing perioperative mortality or cardiac
benefits and adverse effects, a quantitative systematic review may
complications, or both. Studies were included if they measured one
help determine their overall efficacy and safety.
or more relevant outcomes, which included death, MI, heart failure
(HF), acute stroke, supraventricular tachyarrhythmia (SVT) or
Informed decisions.
myocardial ischaemia. In addition, studies with similar objectives Searching other resources
to our review were included, even if these same studies did not
We entered all trials selected for inclusion into the Science
report any relevant outcome events (i.e. death, MI, HF, acute stroke,
Citation Index to identify any additional relevant articles. The
SVT, myocardial ischaemia).
bibliographies of all included articles and published reviews
Primary outcomes were searched to identify any other potentially relevant studies
for inclusion. Additionally, we searched clinical trial registries,
1. All-cause mortality within 30 days after surgery: any reported namely ClinicalTrials.gov and the World Health Organization (WHO)
death. The time period for outcome ascertainment in each trial International Clinical Trials Registry Platform (ICTRP), for published
was also documented. studies meeting our inclusion criteria. These additional searches
were completed in May 2017.
Secondary outcomes
1. Cardiac mortality within 30 days after surgery: sudden death or Data collection and analysis
death resulting from a primarily identifiable cardiac cause. The Selection of studies
time period for outcome ascertainment in each trial was also
documented. Two authors (DD, AS) independently performed literature searches
2. MI within 30 days after surgery: definition as per individual study for potentially relevant RCTs. All identified published full papers
(specific criteria employed were documented). The time period and abstracts were assessed independently for inclusion by the
for outcome ascertainment in each trial was also documented. same two authors. We applied no language restrictions. We
documented the reasons for exclusion for all excluded studies. We
3. Myocardial ischaemia within 30 days after surgery: as
resolved all disagreements by consensus or involvement of a third
detected on an electrocardiogram (ECG) or trans-oesophageal
author (DNW).
echocardiogram (specific criteria employed were documented).
The time period for outcome ascertainment in each trial was also Data extraction and management
documented.
4. SVT within 30 days after surgery: SVT, atrial fibrillation or atrial Two authors (DD, AS) independently extracted data from the
flutter. The time period for outcome ascertainment in each trial included studies on a predesigned data abstraction form (Appendix
was also documented. 2). These same two authors independently entered all data into
Review Manager 5 (RevMan 2014). We were not blinded to study
5. HF within 30 days after surgery: clinical diagnosis of HF
authors, institution or journal when performing data abstraction.
or need for postoperative intra-aortic balloon pump support
Where necessary, we contacted authors of published trials to
(applicable only for cardiac surgery). The time period for
provide any additional information required for the analyses (see
outcome ascertainment in each trial was also documented.
Methods of the review).
Adverse effects from treatment
Assessment of risk of bias in included studies
1. Acute stroke within 30 days after surgery: new focal neurological
Two authors (DD, AS) independently evaluated the quality of all
deficit with signs and symptoms lasting longer than 24 hours.
included trials using the criteria recommended by the Cochrane
The time period for outcome ascertainment in each trial was also
Anaesthesia, Critical and Emergency Care (ACE) Group. These
documented.
criteria emphasize the adequacy of allocation concealment,
Physiological effects of treatment randomization, blinding and intention-to-treat (ITT) analysis. Each
included study was evaluated using the Cochrane 'Risk of bias' tool
1. Bradycardia requiring pharmacological or pacemaker treatment (Higgins 2011a). We were not blinded to study authors, institution
during the period of study drug administration. or journal when performing quality assessment.
2. Hypotension requiring treatment with inotropes or
vasopressors during the period of study drug administration. Measures of treatment effect
Search methods for identification of studies We performed all statistical analyses using Review Manager 5
(RevMan 2014). Given that all outcomes and adverse effects were
Electronic searches dichotomous, all treatment effects were expressed as pooled risk
ratios (RR) with 95% confidence intervals (CI).
We searched the Cochrane Central Register of Controlled Trials
(CENTRAL, 2017, Issue 4), MEDLINE (1950 to April week 4 2017), Unit of analysis issues
Embase (1980 to May 2017), the Science Citation Index and
reference lists of articles. The Ovid platform was used for searching We excluded cross-over trials and cluster randomized trials in this
the electronic databases. review. If a study had multiple treatment arms, comparisons were
made between α-2 adrenergic agonist and placebo, or between α-2
We searched MEDLINE using the search terms presented in adrenergic agonist and inactive control.
Appendix 1. We then limited the studies to those identified
simultaneously by a highly sensitive search strategy for identifying Dealing with missing data
RCTs in MEDLINE (Dickersin 1994). Our search strategies for If a study had missing relevant data in the published report, we
CENTRAL and Embase are presented in Appendix 1. attempted to contact the study authors up to three times to obtain
these data. If data were missing due to participant attrition, and
imputation methods were not used in the published report, we
employed complete case analysis when importing the data.
Informed decisions.
Assessment of heterogeneity Sensitivity analysis

We measured heterogeneity using the I2 statistic: the proportion of We planned several sensitivity analyses a priori to characterize the
total variation explained by between-study variation as opposed to influence of study quality and outcome definitions on the overall
chance (Higgins 2002; Higgins 2003). Higher I2 statistics imply more results.
heterogeneity between studies than would be expected by chance
alone. 1. We restricted the meta-analyses to the subset of studies
that clearly reported methods for blinding and allocation
Assessment of reporting biases concealment.
2. We determined the effect of α-2 adrenergic agonists on MI in
We carried out funnel plot analyses to assess for publication bias
the subset of RCTs that strictly defined MI a priori as either
(Egger 1997), with formal tests for asymmetry being performed
significant new Q waves on an ECG or significant elevations in
only if meta-analyses pooled data from 10 or more studies (Higgins
enzymatic markers of cardiac injury (MB isoenzyme of creatinine
2011b).
kinase, troponin-I, troponin-T).
Data synthesis 3. We determined the effect of α-2 adrenergic agonists on
myocardial ischaemia in the subset of RCTs that strictly defined
Given the clinical heterogeneity between cardiac and non- ischaemia a priori as ST segment depression or elevation of 0.1
cardiac surgery, we conducted analyses for these two subgroups mV or greater for one minute or longer.
separately. If an individual study included both cardiac and non-
cardiac surgery procedures, we attempted to obtain subgroup- In addition, we performed four additional post-hoc analyses.
specific results from the authors. If such data were not available,
and greater than 75% of participants underwent cardiac surgical 1. Significant statistical heterogeneity was identified when
procedures, the specific study was allocated to the cardiac surgery calculating the pooled effect of α-2 adrenergic agonists on
subgroup. Conversely, the study was allocated to the non-cardiac hypotension during non-cardiac surgery. To explore potential
surgery subgroup if greater than 75% of participants underwent explanations for this heterogeneity, we conducted subgroup
non-cardiac surgical procedures. In all other cases, the specific analyses based on the specific agent (i.e. clonidine, mivazerol
study was excluded from the review. In the presence of low or dexmedetomidine) in the included trials. A statistical test of
heterogeneity (I2 statistic 25% or less) (Higgins 2003), pooled RRs interaction was used to assess for the presence of a subgroup
were calculated using the fixed-effect model. In the presence effect.
of moderate-to-significant heterogeneity (I2 statistic greater than 2. During the course of the review, we identified several very large
25%) (Higgins 2003), we used the random-effects model and carried included RCTs that might have highly influenced the overall
out post-hoc analyses to attempt to explain the heterogeneity. pooled estimates. Therefore, we conducted a sensitivity analysis
that excluded these very large RCTs.
Subgroup analysis and investigation of heterogeneity 3. Mivazerol is an experimental α-2 adrenergic agonist that was
A priori, we planned several subgroup analyses to determine studied in several relatively large trials, but never proceeded
the potential influence of the surgical procedure, the specific through the approval process for clinical use. At the request of
α-2 adrenergic agonist employed and coexistent therapies on external peer reviewers of this review, we conducted a sensitivity
the overall results. Subgroup-specific results were only calculated analysis that excluded trials that evaluated mivazerol.
if there were two or more studies within the subgroup. These 4. Several relevant studies were conducted prior to 1997, during
subgroup analyses were as follows. a period when perioperative practice might not necessarily
be generalizable to contemporary practice. At the request of
1. Treatment effects of α-2 adrenergic agonists on mortality (all- external peer reviewers of this review, we conducted a sensitivity
cause and cardiac-cause), MI and ischaemia based on the type analysis that excluded trials where data were collected prior to
of non-cardiac surgical procedure, namely vascular versus non- 1997.
vascular non-cardiac surgery. If a variety of surgical procedures
were included in a study, we attempted to obtain subgroup- 'Summary of findings' tables and GRADE
specific results from the authors. If such data were not available,
To characterize the confidence in the pooled estimated treatment
and greater than 75% of participants underwent the same class
effects better, we used GRADE methodology to assess the quality
of surgery, the specific study was allocated to that specific
of evidence (Guyatt 2008). We generated 'Summary of findings'
subgroup. Failing that, the specific study was excluded from the
tables that separately presented pooled treatment effect estimates
subgroup analysis based on procedure type. We used statistical
for the subgroups of participants who underwent non-cardiac
tests of interaction to assess for the presence of any subgroup
surgery and cardiac surgery. To facilitate this process, data
effects.
from the meta-analyses in Review Manager 5 (RevMan 2014),
2. We calculated treatment effects for each of clonidine, mivazerol were initially exported into GRADEpro. The GRADE approach
and dexmedetomidine on mortality (all-cause and cardiac- rates quality of evidence as high, moderate, low or very low
cause), and MI in non-cardiac surgery. Statistical tests of (GRADE Handbook 2013). Since all data included in this review
interaction were used to assess for the presence of any subgroup were from RCTs, the quality of evidence for each outcome of
effects. interest was initially rated as high level, and then potentially
downgraded up to three levels based on any deficiencies in
the quality of the underlying evidence. The quality of evidence
underlying each pooled treatment effect estimate was assessed
with respect to the risk of bias, inconsistency, indirectness,
Informed decisions.
imprecision and publication bias (Balshem 2011). The anticipated RESULTS

risk for comparison of each outcome was determined based on the
event rate in the control group. Only outcomes judged as critically Description of studies
important, based on their impact on patient health or clinical
Results of the search
decision-making, were chosen for presentation in the 'Summary of
findings' tables. In this present review, we included the following Our search results are presented in Figure 1. The authors identified
outcomes in the 'Summary of findings' tables, provided that 3099 separate papers in the literature search and three additional
relevant estimated pooled treatment effects were present: all- papers from other sources and in total read 389 papers in full.
cause mortality, cardiac mortality, MI, acute stroke, bradycardia
and hypotension.
Informed decisions.
Figure 1. Study flow diagram.
Informed decisions.
Included studies Intervention and comparators

We included 47 trials, which encompassed 17,039 participants (Abi- The number of studies that assessed dexmedetomidine was 24,
Jaoude 1993; Ammar 2016; Bergese 2010; Chi 2016; Cho 2016; clonidine was 21 and mivazerol was two. Treatment duration
Corbett 2005; Devereaux 2014a; Djaiani 2016; Dorman 1993; El- ranged from a single preoperative dose to a 72-hour course of
Kerdawy 2004; Ellis 1994; Ghignone 1986; Ghignone 1987; Helbo- treatment. With the exception of seven studies (Corbett 2005;
Hansen 1986; Herr 2003; Jalonen 1997; Khalil 2013; Kim 2014a; Djaiani 2016; Herr 2003; Liu 2016; Park 2014; Shehabi 2009;
Lee 2013a; Li 2017; Lipszyc 1991; Liu 2016; Loick 1999; Matot Venn 2001), all trials compared α-2 adrenergic agonists against
2000; McSPI-Europe 1997; Myles 1999; Oliver 1999; Park 2014; Patel inactive control. Of the four studies with active controls, one
2016; Pawlik 2005; Pluskwa 1991; Quintin 1993; Quintin 1996; Ren compared dexmedetomidine to morphine (Shehabi 2009), whereas
2013; Shehabi 2009; Soliman 2016; Stuhmeier 1996; Su 2016; Talke the remainder were comparisons of dexmedetomidine versus
1995; Talke 2000; Venn 1999; Venn 2001; Viviano 2012; Wallace propofol.
2004; Wijeysundera 2014a; Xu 2014; Yin 2002). These studies are
described in detail in the Characteristics of included studies tables. All studies that evaluated dexmedetomidine employed the IV
route of administration. Dexmedetomidine was administered
Twenty four studies with 2672 participants involved cardiac surgery intraoperatively in 15 studies, with administration being continued
alone (Abi-Jaoude 1993; Ammar 2016; Chi 2016; Cho 2016; Corbett postoperatively in nine of them. The duration of postoperative
2005; Djaiani 2016; Dorman 1993; El-Kerdawy 2004; Ghignone 1986; administration varied across these nine studies, ranging from
Helbo-Hansen 1986; Herr 2003; Jalonen 1997; Khalil 2013; Kim continuation until arrival to the critical care unit, to continuation for
2014a; Li 2017; Liu 2016; Loick 1999; Myles 1999; Park 2014; Patel 48 hours. Nine additional studies investigated dexmedetomidine
2016; Quintin 1993; Ren 2013; Shehabi 2009; Venn 1999). In all cases, that was administered entirely after surgery in the critical care unit.
the procedure involved was coronary artery bypass graft surgery or Both studies of mivazerol administered the drug IV starting from
valve replacement surgery. the intraoperative period, with continuation until 72 hours after
surgery.
Of the 23 studies with 14,367 participants that involved non-cardiac
surgery (Bergese 2010; Devereaux 2014a; Ellis 1994; Ghignone 1987; There was considerable variation in the administration regimens
Lee 2013a; Lipszyc 1991; Matot 2000; McSPI-Europe 1997; Oliver used in trials that assessed clonidine. It was administered
1999; Pawlik 2005; Pluskwa 1991; Quintin 1996; Soliman 2016; intraoperatively by the IV route in three studies, with one of
Stuhmeier 1996; Su 2016; Talke 1995; Talke 2000; Venn 2001; Viviano these studies also administering an oral loading dose before
2012; Wallace 2004; Wijeysundera 2014a; Xu 2014; Yin 2002), eight surgery. A single study used IV clonidine that was administered
involved vascular procedures exclusively (Lipszyc 1991; McSPI- only preoperatively (i.e. 30 minutes prior to surgery). Four studies
Europe 1997; Pluskwa 1991; Quintin 1996; Soliman 2016; Stuhmeier employed clonidine administered using the combination of an oral
1996; Talke 1995; Talke 2000), and seven involved non-vascular preoperative loading dose, and subsequent maintenance via the
procedures exclusively (Ghignone 1987; Lee 2013a; Matot 2000; transdermal route for 72 hours. Finally, 12 studies administered
Pawlik 2005; Venn 2001; Viviano 2012; Xu 2014). One non-cardiac clonidine orally before surgery, with three of them administering an
surgery study presented subgroup-specific results for both vascular additional intraoperative dose via the nasogastric route.
and non-vascular procedures (Oliver 1999).
Funding
Sample size
Thirty-two studies reported their funding sources, whereas 15
The sample sizes of the included trials ranged from 20 participants did not (Abi-Jaoude 1993; Chi 2016; Cho 2016; El-Kerdawy 2004;
to 10,010 participants. Fourteen studies had fewer than 50 Ghignone 1986; Ghignone 1987; Lipszyc 1991; Loick 1999; Myles
participants (Abi-Jaoude 1993; Dorman 1993; Ghignone 1986; 1999; Park 2014; Pluskwa 1991; Quintin 1993; Ren 2013; Stuhmeier
Ghignone 1987; Helbo-Hansen 1986; Lipszyc 1991; Matot 2000; 1996; Viviano 2012). Fourteen studies reported operational funding
Pawlik 2005; Pluskwa 1991; Quintin 1993; Quintin 1996; Talke 1995; from pharmaceutical companies (Bergese 2010; Djaiani 2016;
Talke 2000; Venn 2001), 14 studies had 50 to 100 participants Helbo-Hansen 1986; Herr 2003; Jalonen 1997; Li 2017; McSPI-
(Ammar 2016; Chi 2016; Corbett 2005; El-Kerdawy 2004; Ellis 1994; Europe 1997; Oliver 1999; Quintin 1996; Su 2016; Talke 1995; Talke
Jalonen 1997; Khalil 2013; Lee 2013a; Liu 2016; Loick 1999; Patel 2000; Venn 1999; Venn 2001), and the remaining 18 studies reported
2016; Viviano 2012; Xu 2014; Yin 2002), and 19 studies had greater that no pharmaceutical funds were used to complete the research
than 100 participants (Bergese 2010; Cho 2016; Devereaux 2014a; (Ammar 2016; Corbett 2005; Devereaux 2014a; Dorman 1993; Ellis
Djaiani 2016; Herr 2003; Kim 2014a; Li 2017; McSPI-Europe 1997; 1994; Khalil 2013; Kim 2014a; Lee 2013a; Liu 2016; Matot 2000;
Myles 1999; Oliver 1999; Park 2014; Ren 2013; Shehabi 2009; Patel 2016; Pawlik 2005; Shehabi 2009; Soliman 2016; Wallace 2004;
Soliman 2016; Stuhmeier 1996; Su 2016; Venn 1999; Wallace 2004; Wijeysundera 2014a; Xu 2014; Yin 2002). Several studies in the latter
Wijeysundera 2014a). group reported that a pharmaceutical company supplied the study
drug as in-kind support, and explicitly stated no further funds were
Demographics of sample received from the company.
The mean age of participants in most studies was 60 to 70 years.
Excluded studies
In addition, the ratio of men to women in the included studies was
skewed, with trials generally recruiting disproportionally more men After the full-text articles were reviewed, we excluded 337
(Characteristics of included studies table). studies. The reasons for these exclusions are presented in the
Characteristics of excluded studies table, as well as the study
flow diagram (Figure 1). The most common reason for exclusion
was study objectives that differed from this present review (312
Informed decisions.
excluded studies). In these cases, the focus of these studies included in the previous 2009 version of this review (Wijeysundera
was to answer a question unrelated to the efficacy or safety 2009), at which point these issues with scientific misconduct had
of α-2 adrenergic agonists for reducing mortality or cardiac not yet been identified (Boldt 1996; Wahlander 2005).
complications (e.g. assessing the efficacy of these drugs for
providing analgesia). Of the remaining articles, 14 were excluded Studies awaiting classification
because the experimental design was not an RCT, three were No studies are currently awaiting classification.
excluded since participants did not undergoing surgery and three
were excluded due to an ineligible population. Two studies Ongoing studies
could not be classified into either the cardiac or non-cardiac
surgery subgroups, and were therefore excluded (Martin 2003; We found no ongoing studies.
Triltsch 2002). A further two studies were excluded because the
Risk of bias in included studies
intervention was administered via an ineligible route (Nader 2009;
Tzortzopoulou 2009), while one study was excluded due to lack of The methodological quality of included studies is shown in the 'Risk
a control arm (Moghadam 2012). Three reports of two individual of bias' figures (Figure 2; Figure 3). A visual summary of judgements
studies were excluded due to concerns about scientific misconduct about the quality and risk of bias for each trial is presented in Figure
(Boldt 1996; Wahlander 2005). In each of these cases, a lead 3. Details explaining the judgements for each domain are presented
author was found to have conducted scientific misconduct (Anon in the 'Risk of bias' tables (Characteristics of included studies).
2013; Rasmussen 2011; Wise 2013). Notably, both studies had been
Figure 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages
across all included studies.
Informed decisions.
Figure 3. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Informed decisions.
Figure 3. (Continued)
Allocation were not described in adequate detail. Concealment of allocation

sequence was generally poor with only 18 studies reporting
Of the 47 included trials, only 28 were judged to have adequate
methods associated with low risk of bias, while six studies
methods of generating allocation sequences. Of the remaining 19
described methods associated with a high risk of bias (Bergese
studies, two trials used methods likely to produces bias (Helbo-
2010; Corbett 2005; Khalil 2013; Lee 2013a; Lipszyc 1991; Liu 2016).
Hansen 1986; Lipszyc 1991), while the remaining trials were
classified as having unclear risk of bias because the methods
Informed decisions.
Only 16 studies reported adequate allocation sequence generation 0.80, 95% CI 0.61 to 1.04, P = 0.10), without any measurable
and allocation concealment. heterogeneity (I2 = 0%) (Analysis 1.1). The quality of this evidence
was high (Summary of findings for the main comparison).
Blinding
Secondary outcomes
Although 31 studies described themselves as double-blind, only 21
clearly reported adequate methods for how blinding was achieved. 1. Cardiac mortality within 30 days after surgery: sudden death or
Of the remaining 26 studies, 14 were open-label and therefore death resulting from a primarily identifiable cardiac cause
assessed to be high risk of bias, while the others were judged to Five studies reported cardiac-related deaths, with 114 events
have an unclear risk of bias. Outcome assessment was blinded in 21 (0.9%) among 12,525 participants. Alpha-2 adrenergic agonists did
trials, and therefore judged to be at low risk of bias. Only 16 trials not cause a statistically significant reduction in cardiac-related
demonstrated blinding of participants, personnel and outcome mortality (RR 0.86, 95% CI 0.60 to 1.23, P = 0.41) with low
assessors.
measurable heterogeneity (I2 = 16%) (Analysis 1.2). The quality of
Incomplete outcome data evidence was high (Summary of findings for the main comparison).
Thirty trials reported no exclusions, exclusions deemed to be 2. Myocardial infarction within 30 days after surgery (definition as per
appropriate and ITT analysis. For four trials, exclusions (Lee individual study)
2013a; Oliver 1999; Quintin 1996; Stuhmeier 1996), were either Twelve studies reported MIs, with 835 events (6.0%) among 13,907
not reported or judged as being excessive enough to likely cause participants. Alpha-2 adrenergic agonists were not associated with
bias. The remainder either failed to use ITT analysis or adequately any statistically significant difference in the risk of MI (RR 0.94, 95%
account for exclusions. Only 11 studies reported a flow diagram CI 0.69 to 1.27, P = 0.67) with moderate heterogeneity (I2 = 37%)
of participants in the trial (Bergese 2010; Chi 2016; Devereaux (Analysis 1.3). The quality of evidence was moderate (Summary of
2014a; Kim 2014a; Lee 2013a; Li 2017; Liu 2016; Shehabi 2009; Su findings for the main comparison).
2016; Viviano 2012; Wijeysundera 2014a), as is recommended in the
CONSORT statement (Schulz 2010). 3. Myocardial ischaemia within 30 days after surgery: as detected on
an electrocardiogram or transoesophageal echocardiogram (definition
Selective reporting as per individual study)
Of the 47 trials, 37 demonstrated concordance between outcomes Twelve studies reported myocardial ischaemia, with 291 events
discussed in the methods or protocol and the outcomes reported. (21.1%) among 1379 participants. Alpha-2 adrenergic agonists did
Four studies were judged to be of unclear risk of bias because not significantly reduced the risk of ischaemia (RR 0.73, 95% CI 0.53
they reported adverse events without discussing any surveillance to 1.02, P = 0.06; I2 = 45%) (Analysis 1.4).
methods (Liu 2016; Park 2014; Soliman 2016; Viviano 2012). The
remaining six studies either failed to report major outcomes, or 4. Supraventricular tachycardia within 30 days after surgery:
reported major outcomes not discussed in the relevant methods supraventricular tachycardia, atrial fibrillation or atrial flutter
sections (Corbett 2005; Dorman 1993; Helbo-Hansen 1986; Khalil Two studies reported SVTs, with one event (2.3%) among 44
2013; Oliver 1999; Stuhmeier 1996). participants. Both studies evaluated dexmedetomidine. Since there
was no events reported in one of the studies (Venn 2001), pooled
Other potential sources of bias estimates were not calculated. The remaining trial showed no effect
Five trials had other sources of bias classified as unclear risk or high of α-2 adrenergic agonists on SVT (RR 1.11, 95% CI 0.05 to 24.07)
risk. Two of the trials had high risk of bias due to significant changes (Analysis 1.5) (Talke 1995).
in their methods during the trial recruitment phase. One trial
5. Heart failure within 30 days after surgery: clinical diagnosis of heart
terminated early (Ellis 1994), while the other changed its selection
failure
criteria (Oliver 1999). Three trials were classified as having unclear
risk of bias, because two trials (Lipszyc 1991; Quintin 1993), were Eight studies reported episodes of HF, with 107 events (1.0%)
being published only in abstract form (therefore lacking complete among 10,802 participants. There was no significant reduction in
peer-review), and another lacked reproducible selection criteria congestive heart failure (CHF) with perioperative α-2 adrenergic
(Lee 2013a). agonist use (RR 1.21, 95% CI 0.83 to 1.75, P = 0.32), with negligible
heterogeneity (I2 = 3%) (Analysis 1.6).
Effects of interventions
Adverse effects from treatment
See: Summary of findings for the main comparison Alpha-2
adrenergic agonists compared to control in non-cardiac surgery; 1. Acute stroke within 30 days after surgery: new focal neurological
Summary of findings 2 Alpha-2 adrenergic agonists compared to deficit with signs and symptoms lasting longer than 24 hours
control in cardiac surgery Seven studies reported acute strokes, with 56 strokes (0.5%) among
11,542 participants. Alpha-2 adrenergic agonists had no significant
Non-cardiac surgery
effect on acute stroke (RR 0.93, 95% CI 0.55 to 1.56 P = 0.79) with
Primary outcome no measurable heterogeneity (I2 = 0%) (Analysis 1.7). The quality of
1. All-cause mortality within 30 days after surgery
evidence for effects on acute stroke was high (Summary of findings
for the main comparison).
Sixteen studies reported all-cause mortality, with 210 events
(1.5%) among 14,081 participants. Alpha-2 adrenergic agonists
had no statistically significant reduction in all-cause mortality (RR
Informed decisions.
Physiological effects of treatment 3. Myocardial ischaemia within 30 days after surgery: as detected on
an electrocardiogram or transoesophageal echocardiogram (definition
1. Bradycardia requiring pharmacological or pacemaker treatment as per individual study)
Sixteen studies reported bradycardia, with 1349 events (9.6%) Thirteen studies reported myocardial ischaemia, with 243 events
in 14,035 participants. Within these 16 studies, α-2 adrenergic (21.4%) among 1134 participants. Alpha-2 adrenergic agonists
agonists significantly increased the risk of bradycardia (RR 1.59, significantly reduced the risk of ischaemia (RR 0.69, 95% CI 0.56 to
95% CI 1.18 to 2.13, P = 0.002), albeit with substantial heterogeneity 0.86, P < 0.001) with no heterogeneity (I2 = 0%) (Analysis 2.3).
(I2 = 53%) (Analysis 1.8). The quality of evidence for treatment
effects on bradycardia was moderate (Summary of findings for the 4. Supraventricular tachycardia within 30 days after surgery:
main comparison). supraventricular tachycardia, atrial fibrillation or atrial flutter
2. Hypotension requiring treatment with inotropes or vasopressors Six studies reported SVTs, with 79 events (7.7%) among 1044
participants. Alpha-2 adrenergic agonists had no significant effect
Fifteen studies reported hypotension, with 4766 events (34.7%) on the risk of SVT (RR 0.77, 95% CI 0.50 to 1.16, P = 0.21) with low
in 13,738 participants. Alpha-2 adrenergic agonists caused a measurable heterogeneity (I2 = 24%) (Analysis 2.4).
significant increase in the risk of perioperative hypotension (RR
1.24, 95% CI 1.03 to 1.48, P = 0.02), albeit with substantial 5. Heart failure within 30 days after surgery: clinical diagnosis of heart
heterogeneity (I2 = 54%) (Analysis 1.9). Based on a post- failure or need for postoperative intra-aortic balloon pump support
hoc subgroup analysis, the choice of drug may explain this Four studies reported 38 HF events (6.9%) among 549 participants.
heterogeneity (Analysis 4.4). Specifically, there was statistically Alpha-2 adrenergic agonists had no statistically significant effect
significant evidence of subgroup effects based on whether the on the risk of HF (RR 0.90, 95% CI 0.49 to 1.63, P = 0.72) with no
studies evaluated clonidine, dexmedetomidine or mivazerol (test measurable heterogeneity (I2 = 0%) (Analysis 2.5).
of interaction P < 0.001). Clonidine significantly increased the
risk of hypotension (RR 1.29, 95% CI 1.23 to 1.35, P < 0.001). Adverse effects from treatment
Dexmedetomidine was also associated with an increased risk (RR
1. Acute stroke within 30 days after surgery: new focal neurological
1.81, 95% CI 1.07 to 3.06, P = 0.03). Conversely, mivazerol did
deficit with signs and symptoms lasting longer than 24 hours
not increase the risk of hypotension (RR 0.95, 95% CI 0.82 to
1.10, P = 0.48). Clonidine and mivazerol subgroup analyses had no Seven studies reported acute stroke, with 18 events (1.5%)
measurable heterogeneity (I2 = 0%), whereas the dexmedetomidine among 1175 participants. Alpha-2 adrenergic agonists significantly
subgroup analysis demonstrated significant heterogeneity (I2 = reduced the risk of acute stroke (RR 0.37, 95% CI 0.15 to 0.93, P
50%). The quality of evidence for treatment effects on hypotension = 0.03; I2 = 0%) (Analysis 2.6). The quality of evidence was low
was moderate (Summary of findings for the main comparison). (Summary of findings 2).
Cardiac surgery Physiological effects of treatment
Primary outcome 1. Bradycardia requiring pharmacological or pacemaker treatment
1. All-cause mortality within 30 days after surgery Ten studies reported episodes of bradycardia, with 136 events
(9.2%) among 1477 participants. Pooled analysis demonstrated
Sixteen studies reported all-cause mortality, with 29 events (1.5%) that α-2 adrenergic agonists significantly increased the risk of
among 1949 participants. Alpha-2 adrenergic agonists did not bradycardia (RR 1.88, 95% CI 1.35 to 2.62, P = 0.0002) with no
result in a statistically significant reduction in all-cause mortality heterogeneity (I2 = 0%) (Analysis 2.7). The quality of evidence was
(RR 0.52, 95% CI 0.26 to 1.04, P = 0.06), without any measurable moderate (Summary of findings 2).
heterogeneity (I2 = 0%) (Analysis 2.1). The quality of this evidence
was moderate (Summary of findings 2). 2. Hypotension requiring treatment with inotropes or vasopressors
Secondary outcomes Nine studies reported 494 episodes of hypotension (35%) among
1413 participants. Alpha-2 adrenergic agonists did not significantly
1. Cardiac mortality within 30 days after surgery: sudden death or increase the risk of hypotension (RR 1.19, 95% CI 0.87 to 1.64, P
death resulting from a primarily identifiable cardiac cause
= 0.28) in an analysis with substantial heterogeneity (I2 = 72%)
Only one study reported cardiac mortality, with 1 event among (Analysis 2.8). The quality of evidence was low (Summary of
the 12 participants in the clonidine arm and no events among the findings 2).
10 participants in the control arm (Loick 1999). Thus, no pooled
analysis was performed. Subgroup analyses
2. Myocardial infarction within 30 days after surgery: definition as per

Vascular versus non-vascular non-cardiac surgery
individual study There was no statistically significant evidence of subgroup effects
Eight studies reported MIs, with 16 events (2.0%) among 782 based on procedure type (i.e. vascular versus non-vascular
participants. Alpha-2 adrenergic agonists were not associated with procedures) with respect to the outcomes of all-cause mortality
reduced risk of MI (RR 1.01, 95% CI 0.43 to 2.40, P = 0.98) in an (test of interaction P = 0.17; Analysis 3.1), cardiac mortality (test of
analysis with no heterogeneity (I2 = 0%) (Analysis 2.2). The quality interaction P = 0.13; Analysis 3.2), MI (test of interaction P = 0.13;
of evidence was moderate (Summary of findings 2). Analysis 3.3), and myocardial ischaemia (test of interaction P = 0.17;
Analysis 3.4).
Informed decisions.
Drug (i.e. clonidine, mivazerol or dexmedetomidine) evaluated trials, treatment effect on all-cause mortality became statistically
in non-cardiac surgery significant (RR 0.45, 95% CI 0.22 to 0.93, P = 0.03; participants =
2174; studies = 14; Analysis 7.1). Conversely, the effect on cardiac
There was no statistically significant evidence of subgroup effects
mortality (RR 0.47, 95% CI 0.10 to 2.25, P = 0.35; participants =
based on the specific α-2 adrenergic agonist evaluated with respect
618; studies = 3; Analysis 7.2), and MI (RR 0.56, 95% CI 0.25 to
to the outcomes of all-cause mortality (test of interaction P = 0.50)
1.25, P = 0.16; participants = 2000; studies = 10; Analysis 7.3) were
(Analysis 4.1), and MI (test of interaction P = 0.48) (Analysis 4.3).
statistically non-significant, albeit with more optimistic individual
Conversely, there was a statistically significant subgroup effect with
point estimates (i.e. pooled treatment effects shifted towards larger
respect to cardiac mortality (test of interaction P = 0.05) (Analysis
risk reductions).
4.2). In these subgroup analyses, mivazerol significantly reduced
cardiac mortality (RR 0.51, 95% CI 0.27 to 0.98, P = 0.04), whereas Excluding drugs not introduced into clinical practice (i.e.
clonidine did not (RR 1.12, 95% CI 0.71 to 1.75, P = 0.63). There mivazerol)
were insufficient studies that reported myocardial ischaemia as
an outcome for dexmedetomidine or mivazerol to facilitate drug- In post-hoc sensitivity analyses excluding the two trials that
specific subgroup analysis for the outcome. evaluated mivazerol (McSPI-Europe 1997; Oliver 1999), there was
no change in pooled treatment effects pertaining to all-cause
Sensitivity analyses mortality, cardiac mortality, MI, SVT, HF, stroke, bradycardia, or
hypotension (Analysis 8.1; Analysis 8.2; Analysis 8.3; Analysis 8.5;
Studies that clearly reported blinding and concealed allocation
Analysis 8.6; Analysis 8.7; Analysis 8.8; Analysis 8.9). Conversely,
The pooled effects of α-2 adrenergic agonists on all-cause mortality the pooled treatment effect on ischaemia became statistically
(RR 0.68, 95% CI 0.41 to 1.11, P = 0.12; participants = 13,066; significant (RR 0.68, 95% CI 0.48 to 0.97, P = 0.03; participants =
studies = 7; Analysis 5.1), MI (RR 1.08, 95% CI 0.95 to 1.23, P = 0.26; 1079; studies = 11; I2 = 40%) (Analysis 8.4), albeit in an analysis with
participants = 13,026; studies = 6; Analysis 5.2), and myocardial moderate heterogeneity and relatively few participants.
ischaemia (RR 0.77, 95% CI 0.40 to 1.48, P = 0.43; participants = 412;
studies = 3; Analysis 5.3) were qualitatively similar when analyses Restricting studies more representative of contemporary
were restricted to trials that clearly reported methods for blinding perioperative practice
and allocation concealment. When analyses pertaining to non-cardiac surgery were restricted
to studies that collected data within the previous 20 years, there
Strict definitions of myocardial infarction and ischaemia
was no change in the pooled treatment effects pertaining to all-
When analyses were restricted to trials that strictly defined MI on cause mortality, cardiac mortality, MI, HF or stroke (Analysis 9.1;
ECG or enzymatic criteria, pooled treatment effects in non-cardiac Analysis 9.2; Analysis 9.3; Analysis 9.5; Analysis 9.6). Nonetheless,
surgery (RR 0.98, 95% CI 0.70 to 1.36, P = 0.90; participants = 13,003; exclusion of older studies resulted in a significant reduction in
studies = 8) and cardiac surgery (RR 0.76, 95% CI 0.19 to 2.98, P = the risk of myocardial ischaemia (RR 0.51, 95% CI 0.28 to 0.93,
0.69; participants = 275; studies = 3) were qualitatively unchanged P = 0.03; participants = 634; studies = 6; I2 = 48%) in an analysis
(Analysis 6.1). When analyses were restricted to studies that strictly with moderate heterogeneity (Analysis 9.4). In cardiac surgery,
defined events of myocardial ischaemia, the effects in non-cardiac exclusion of older studies resulted in no substantive effect on the
surgery remained non-significant (RR 0.76, 95% CI 0.54 to 1.07, P pooled treatment effects for MI, myocardial ischaemia, SVT, HF or
= 0.12; participants = 1175; studies = 9). In cardiac surgery, the stroke (Analysis 10.2; Analysis 10.3; Analysis 10.4; Analysis 10.5;
sensitivity analysis continued to demonstrate a reduction in the risk Analysis 10.6). Conversely, the pooled treatment effect on all-cause
of ischaemia (RR 0.71, 95% CI 0.55 to 0.91, P = 0.007; participants = mortality became statistically significant (RR 0.47, 95% CI 0.23 to
820; studies = 8) (Analysis 6.2). 0.97; participants = 1782; studies = 13; I2 = 0%) (Analysis 10.1).
Influence of two large trials Funnel plots
The overall results of this review are likely highly influenced by Funnel plots of included studies revealed no obvious publication
two large RCTs in non-cardiac surgery, one of which assessed bias with regard to the outcome of mortality (Figure 4), but some
mivazerol (Oliver 1999), while the other assessed clonidine possible bias with regard to MI (Figure 5). Since this analysis
(Devereaux 2014a). Therefore, we performed a post-hoc sensitivity pooled results from only nine studies, formal statistical testing for
analysis that excluded these studies. After excluding these two asymmetry was not conducted.
Informed decisions.
Figure 4. Funnel plot of comparison: 1 Alpha-2 adrenergic agonists versus control in non-cardiac surgery, outcome:
1.1 All-cause mortality.
Informed decisions.
Figure 5. Funnel plot of comparison: 1 Alpha-2 adrenergic agonists versus control in non-cardiac surgery, outcome:
1.3 Myocardial infarction.
DISCUSSION we are confident that the overall findings of our systematic

review, namely that α-2 adrenergic agonists do not significantly
Summary of main results reduce risks of cardiovascular complications or mortality when
given prophylactically before major non-cardiac or cardiac surgery,
Our present review found high-quality evidence that perioperative
can be reasonably extrapolated to contemporary perioperative
α-2 adrenergic agonists did not reduce the risk of all-cause
practice.
mortality, cardiac mortality or MI in people undergoing non-
cardiac or cardiac surgery (Summary of findings for the main Nonetheless, there were insufficient participants within specific
comparison; Summary of findings 2). These findings remained subgroups to conclusively evaluate several potential benefits of
stable in sensitivity analyses restricted to studies that either α-2 adrenergic agonists, namely prevention of stroke, myocardial
demonstrated low risks of bias or employed strict definitions ischaemia and all-cause mortality after cardiac surgery. The
of MI. Aside from lacking any beneficial effect on these clinical subgroup analysis evaluating effects on stroke during cardiac
outcomes, α-2 adrenergic agonists also conferred important risks, surgery was small, with only seven included studies that
specifically increased rates of hypotension and bradycardia. While encompassed 1175 participants (Analysis 2.6). The pooled estimate
these haemodynamic effects were not associated with an increased was based on low-quality data, calculated using very few outcome
risk of acute stroke, the 95% CIs for this pooled effect were wide (RR events (i.e. 18 strokes). Previous research has found that treatment
0.93, 95% CI 0.55 to 1.56), thereby not excluding the possibility of a effects are generally overestimated in meta-analyses that include
moderate increase in stroke risk with perioperative α-2 adrenergic relatively few outcome events (Thorlund 2011). Consistent with this
agonists. possibility, the magnitude of the pooled estimate was somewhat
implausible (RR 0.37, 95% CI 0.15 to 0.93), in that it suggested a 63%
Overall completeness and applicability of evidence relative reduction in the risk of stroke from a single perioperative
The 47 RCTs included in this systematic review encompassed intervention. Therefore, further research is needed to determine
17,039 participants, a wide range of relevant surgical procedures whether α-2 adrenergic agonists can truly reduce the risk of acute
performed in several different countries internationally and stroke after cardiac surgery.
clinically relevant dosing regimens of currently available
α-2 adrenergic agonists (i.e. clonidine, dexmedetomidine). Similarly, the statistically significant pooled treatment effect on all-
Furthermore, a significant number of participants from the cause mortality was observed only in a post-hoc subset analysis
included studies underwent surgery within the past decade. Thus, restricted to cardiac surgery trials conducted after 1997 (Analysis
Informed decisions.
10.1). This subset was relatively small (13 studies encompassing The quality of evidence for the effects of α-2 adrenergic agonists
1782 participants), the pooled estimated was calculated using very in cardiac surgery was generally lower, largely due to imprecision
few outcome events (i.e. 28 deaths) and the magnitude of the resulting from significantly fewer participants in the pooled
pooled estimate was somewhat implausible (RR 0.47, 95% CI 0.23 analyses (Summary of findings 2). The quality of evidence for
to 0.97) for a single intervention. More studies are needed to assess all outcomes was downgraded because the optimal information
the effect of α-2 adrenergic agonists on all-cause mortality after size of 2000 participants was not achieved, and the 95% CIs of
cardiac surgery. the pooled estimates did not rule out clinically significant effects
(GRADE Handbook 2013). Thus, the quality of evidence for the
In a separate subgroup analysis in cardiac surgery, α-2 adrenergic analyses pertaining to all-cause mortality and MI was moderate.
agonists also caused a significant reduction in perioperative As there were very few outcomes events in the analysis of acute
myocardial ischaemia (Analysis 2.3). Nonetheless, myocardial stroke (i.e. 18 strokes), it was downgraded another level and judged
ischaemia is a surrogate outcome with important associated as low quality. Finally, the presence of substantial imprecision
limitations (Svensson 2013). Especially in the absence of associated in pooled analysis pertaining to hypotension led to the quality
reductions in clinical important and patient-relevant outcomes of this evidence being downgraded to low (I2 = 72%; Analysis
such as mortality or MI, isolated reductions in perioperative 2.8). Nonetheless, the magnitude of the association between α-2
myocardial ischaemia are not sufficient justifications for employing adrenergic agonists and hypotension in cardiac surgery (RR 1.19,
α-2 adrenergic agonists in clinical practice. 95% CI 0.87 to 1.64) was qualitatively very similar to that observed
in non-cardiac surgery (RR 1.24, 95% CI 1.03 to 1.48), where the
Quality of the evidence quality of evidence was moderate.
This systematic review was supported by 47 RCTs that recruited
17,039 participants. The sample size of the included RCTs varied Potential biases in the review process
greatly, ranging from 20 to over 10,000 participants. Nineteen There were several limitations to our review process. First, while our
studies had over 100 participants, with only two studies involving search was exhaustive in that it covered all major medical indexes
over 1000 participants (Devereaux 2014a; Oliver 1999). The vast and clinical trial registries, we might have missed some published
majority of these participants (14,367) were recruited into the trials only listed in other less commonly used indices. Nonetheless,
23 included trials in non-cardiac surgery. By comparison, the we believe it unlikely that our search strategy missed any relevant
remaining 24 RCTs in cardiac surgery involved 2672 participants. studies of at least moderate size and quality. Second, we only
included studies reporting subgroup-specific outcome data based
Only 16 studies reported adequate methods for random sequence
on surgical procedure type (i.e. cardiac surgery versus non-cardiac
generation and allocation concealment. Furthermore, although 31
surgery). Consequently, we excluded any study that did not
studies described themselves as 'double-blinded,' only 21 studies
predominantly include procedures (greater than 75%) from either
reported appropriate methods to achieve blinding. Nonetheless,
of these surgical procedure subgroup, unless subgroup-specific
the majority of participants were from well-designed studies with
outcome data could be obtained from the authors. Consequently,
adequate methods for allocation and blinding, thereby rendering
two otherwise eligible studies could not be included in this
them low risk to be influenced by selection bias, performance bias
systematic review (Martin 2003; Triltsch 2002). In excluding these
and detection bias.
studies, we balanced the risk of biasing the analyses with the loss
The analyses pertaining to the primary and secondary outcomes of additional data, and chose the latter to maintain the integrity of
in people undergoing non-cardiac surgery were generally robust. our analyses.
These findings were judged as moderate to high quality by GRADE
methodology (Summary of findings for the main comparison). Agreements and disagreements with other studies or
Although many studies failed to report adequate methods to reviews
avoid risk of bias, the specific outcomes were unlikely to be There are several potential reasons why the theoretically beneficial
influenced and thus no downgrading of quality was necessary. physiological effects of α-2 adrenergic agonists did not translate
In addition, there was a potential threat of indirectness since into reduced rates of major postoperative cardiac complications.
the second largest RCT evaluated mivazerol (Oliver 1999), which First, α-2 adrenergic agonists might not have sufficiently reduced
is not available for clinical use. However, given the similarity of heart rates to mitigate the risks of perioperative MI, as has
mivazerol to dexmedetomidine (which is available for clinical use), been previously proposed (Devereaux 2014a). This hypothesis
we reasoned that this risk was likely not serious. Conversely, is supported by the observation that, while perioperative β-
funnel plots suggested that the pooled treatment effects on MI was blockers caused more significant bradycardia than α-2 adrenergic
affected by publication bias (Figure 5). The asymmetry in the funnel agonists, rates of perioperative MI were reduced with β-blockers
plots was produced by two small studies with seemingly unrealistic but not α-2 adrenergic agonists (Wijeysundera 2014b). Second,
effect sizes (Ellis 1994; Stuhmeier 1996). While the combined the predominant mechanism underlying perioperative MI in many
weight of these studies was less than 3% of the pooled analysis, affected people might not be increases in blood pressure and
we downgraded the evidence by one level because of suspicion heart rate induced by the surgical stress response. For example,
of publication bias for an outcome known to be influenced by almost 30% of people with postoperative MI do not have significant
performance bias (Analysis 1.3). Finally, the quality of evidence for obstructive coronary artery disease (Sheth 2015). It is unlikely that
the physiological effects of bradycardia and hypotension were both limiting perioperative increases in heart rate would help prevent MI
downgraded because of substantial heterogeneity (I2 greater than in such people. Third, at a population-level, the beneficial effects
50%) in the analyses (Analysis 1.8; Analysis 1.9). of heart rate reduction in some people undergoing surgery might
have been offset by equal numbers of people who experienced
deleterious effects from significant perioperative hypotension.
Informed decisions.
Notably, our overall findings with respect to the absence of study utilized a substantially larger data set than previous reviews
major reductions in perioperative cardiovascular risk from α-2 (Biccard 2008; Nishina 2002; Stevens 2003; Wijeysundera 2003;
adrenergic agonists was somewhat consistent with results seen Wijeysundera 2009). Finally, we performed multiple sensitivity
with prophylactic therapy with other sympatholytic agents. analyses to assess the potential influence of study quality, outcome
Specifically, β-adrenergic blockers have been shown to cause a definition and publication bias on our overall conclusions.
net harmful effect in non-cardiac surgery (Wijeysundera 2014b).
It remains to be seen whether any strategy of prophylactically Limitations
attenuating haemodynamic abnormalities with sympatholytic Our review had several limitations that should be considered.
agents can safely reduce perioperative cardiac risk. Indeed, First, the results were heavily influenced by two large trials
if future RCTs with either alternative regimens of previously of mivazerol (Oliver 1999) and clonidine (Devereaux 2014a) in
evaluated sympatholytic agents (i.e. α-2 adrenergic agonists, β- non-cardiac surgery. While excluding these large trials from
adrenergic blockers) or alternative negative chronotropic agents the meta-analysis resulted in somewhat more optimistic point
(e.g. ivabradine) fail to show net overall benefit, the general strategy estimates for individual pooled treatment effects, these pooled
for perioperative cardiac risk reduction may have to shift from estimates remained statistically non-significant. Second, as with
prophylactic therapy to early treatment. Specifically, as opposed to any systematic review, our results may have been affected by
administering these medications to a broad group of people before publication bias. Though funnel plots indicated no obvious bias
surgery, clinicians might instead consider targeting treatment in in the reporting of death (all-cause and cardiac-cause), they did
high-risk people identified on the basis of ischaemic ECG changes suggest reporting bias may be present for MI. Third, our present
or elevated cardiac troponin concentrations early after surgery. analysis pooled trials of α-2 adrenergic agonists with differing
selectivity for their target receptors, namely α-2 adrenoceptors and
Comparison of our present systematic review on perioperative α-2
non-adrenergic imidazoline receptors (Khan 1999). Specifically,
adrenergic agonists with a prior systematic review of perioperative
both mivazerol and dexmedetomidine have considerably greater
β-adrenergic blockers in non-cardiac surgery also provides some
selectivity for these target receptors than clonidine. Furthermore,
potential insights into the mechanisms underlying perioperative
when comparing the two large individual trials that dominated
stroke (Wijeysundera 2014b). Specifically, α-2 adrenergic agonists
this meta-analysis (Devereaux 2014a; Oliver 1999), clonidine had no
(RR 1.24, 95% CI 1.03 to 1.48) and β-adrenergic blockers (RR
effect on mortality and increased rates of significant perioperative
1.47, 95% CI 1.34 to 1.60) conferred approximately similar
hypotension, while mivazerol, a more selective α-2 adrenergic
risks of perioperative hypotension. Despite this similarity in
agonist that is not currently available for clinical use, was
haemodynamic effects, β-blockers (RR 1.86, 95% CI 1.09 to
associated with trends towards reduced mortality and had no effect
3.16) conferred significantly increased risks of perioperative acute
on rates of hypotension. Importantly, these contrasting findings
stroke while α-2 adrenergic agonists did not (RR 0.93, 95% CI
might have also been due to the different time periods when the
0.55 to 1.56). These contrasting effects are also evident when
studies were conducted, differences in study design, differences in
comparing two large individual perioperative RCTs of these two
participant characteristics or chance. Nonetheless, the contrasting
different drug classes, namely the POISE-1 trial of metoprolol
findings still suggest that any future RCT of α-2 adrenergic agonists
(POISE 2008) and the POISE-2 trial of clonidine (Devereaux 2014a).
for cardiac risk reduction in people undergoing surgery should
Specifically, while metoprolol (hazard ratio (HR) 1.55, 95% CI 1.38
focus on agents with higher selectivity for α-2 adrenoceptors, such
to 1.74) and clonidine (HR 1.32, 95% CI 1.24 to 1.40) caused
as dexmedetomidine or mivazerol.
qualitatively similar increases in rates of hypotension, metoprolol
significantly increased risks of stroke (HR 2.17, 95% CI 1.26 to AUTHORS' CONCLUSIONS
3.74) while clonidine did not (HR 1.06, 95% CI 0.54 to 2.05). These
findings suggest that, despite the previously observed association Implications for practice
between perioperative hypotension and stroke (POISE 2008), the
mechanisms underlying perioperative acute stroke are likely more Our study found high-quality data to firmly conclude that there are
complex than simply a decrease in perfusion pressure. Further no compelling reasons for employing perioperative α-2 adrenergic
research is needed to better delineate these mechanisms, and agonists to reduce the risks of perioperative death or major
thereby inform the development of strategies to help prevent this cardiac complications in people undergoing surgery. These agents
often devastating perioperative complication (POISE 2008). do not reduce the risks of death, myocardial infarction (MI) or
acute stroke after surgery. Furthermore, they are associated with
Importantly, perioperative α-2 adrenergic agonists do have other important adverse effects, namely increased risks of hypotension
potential benefits that may justify their selective use in some and bradycardia.
people undergoing surgery. Specifically, in a previous systematic
review of 30 small RCTs encompassing 1792 participants, these Implications for research
agents decreased both postoperative pain intensity and morphine
First, randomized controlled trials (RCTs) of clonidine for reducing
consumption (Blaudszun 2012). Our present study provided
perioperative cardiovascular risk should not be performed in
additional data supporting the safety of using α-2 adrenergic
the future because the Perioperative Ischemic Evaluation - 2
agonists as an adjunct therapy for managing postoperative acute
(POISE-2) trial provides compelling evidence that this specific
pain, provided that there is adequate attention to the associated
agent lacks benefit. Second, while it is presently unclear whether
risks of hypotension and bradycardia.
more selective α-2 adrenergic agonists, such as dexmedetomidine
Strengths or mivazerol, have differing effects on clinical outcomes in
comparison to clonidine, there are at least theoretical reasons
Our present review had several strengths. The literature search to pursue this hypothesis in future trials. Thus, future RCTs of
was extensive and encompassed all languages. In addition, our perioperative α-2 adrenergic agonists should focus on these more
Informed decisions.
selective agents. Any such future trial should also adhere to quality help and editorial advice during the preparation of this updated
standards for RCTs including blinding (participants, caregivers, systematic review.
outcome adjudicators), allocation concealment and intention-
to-treat analysis. Third, appropriately designed future RCTs are Dr Wijeysundera is supported in part by a New Investigator Award
needed to determine whether more selective α-2 adrenergic from the Canadian Institutes of Health Research (Ottawa, Ontario,
agonists can help prevent perioperative stroke or all-cause death Canada). Dr Beattie is the Fraser Elliot Chair of Cardiac Anesthesia
after cardiac surgery. at the University Health Network (Toronto, Ontario, Canada). Both
Dr Wijeysundera and Dr Beattie are supported in part by Merit
ACKNOWLEDGEMENTS Awards from the Department of Anesthesia at the University
of Toronto (Toronto, Ontario, Canada). We are indebted to the
We would like to thank Rodrigo Cavallazz (content editor), Cathal following authors who responded to our questions regarding their
D Walsh (statistical editor), Ben Gibbison, Pierre Foex, Ernst-Peter publications: Drs M Fischler, RM Grounds, HM Loick, I Matot, P Myles,
Horn (peer reviewers), Anne Lyddiatt (consumer referee) for their M Oliver, L Quintin, C Spies, P Talke and A Wallace.
Informed decisions.
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Liu X, Zhang K, Wang W, Xie G, Fang X. Dexmedetomidine Pluskwa F, Bonnet F, Saada M, Macquin-Mavier I, Becquemin JP,
sedation reduces atrial fibrillation after cardiac surgery Catoire P. Effects of clonidine on variation of arterial blood
compared to propofol: a randomized controlled trial. Critical pressure and heart rate during carotid artery surgery. Journal
Care 2016;20(1):298. [EMBASE: 612244138] of Cardiothoracic and Vascular Anesthesia 1991;5(5):431-36.
[PUBMED: 1932647]
Loick 1999 {published data only}
Loick HM, Schmidt C, Van Aken H, Junker R, Erren M, Quintin 1993 {published data only}
Berendes E, et al. High thoracic epidural anesthesia, but not Quintin L, Cicala R, Kent M, Thomsen B. Effect of clonidine on
clonidine, attenuates the perioperative stress response via myocardial ischaemia: a double-blind pilot trial. Canadian
sympatholysis and reduces the release of troponin T in patients Journal of Anaesthesia 1993;40(1):85-6. [PUBMED: 7980723]
undergoing coronary artery bypass grafting. Anesthesia and
Analgesia 1999;88(4):701-9. [PUBMED: 10195508] Quintin 1996 {published data only}
Quintin L, Bouilloc X, Butin E, Bayon MC, Brudon JR, Levron JC,
Matot 2000 {published data only}
et al. Clonidine for major vascular surgery in hypertensive
Matot I, Sichel JY, Yofe V, Gozal Y. The effect of clonidine patients: a double-blind, controlled, randomized study.
premedication on hemodynamic responses to Anesthesia and Analgesia 1996;83(4):687-95. [PUBMED:
microlaryngoscopy and rigid bronchoscopy. Anesthesia and 8831304]
Analgesia 2000;91(4):828-33. [PUBMED: 11004033]
Ren 2013 {published data only}
McSPI-Europe 1997 {published data only}
Ren J, Zhang H, Huang L, Liu Y, Liu F, Dong Z. Protective effect
McSPI-Europe Research Group. Perioperative sympatholysis: of dexmedetomidine in coronary artery bypass grafting surgery.
beneficial effects of the alpha 2-adrenoceptor agonist Experimental and Therapeutic Medicine 2013;6(2):497-502.
mivazerol on hemodynamic stability and myocardial ischemia. [PUBMED: 24137215]
Anesthesiology 1997;86(2):346-63. [PUBMED: 9054253]
Informed decisions.
Shehabi 2009 {published data only} care unit: patient and clinician perceptions. British Journal of
Shehabi Y, Grant P, Wolfenden H, Hammond N, Anaesthesia 2001;87(5):684-90. [PUBMED: 11878517]
Bass F, Campbell M, et al. Prevalence of delirium with
Viviano 2012 {published data only}
dexmedetomidine compared with morphine based
therapy after cardiac surgery: a randomized controlled trial Viviano E, Renius M, Ruckert J, C, Bloch A, Meisel C, Harbeck-
(DEXmedetomidine compared to morphine-DEXCOM study). seu A, et al. Selective neurogenic blockade and perioperative
Anesthesiology 2009;111(5):1075-84. [PUBMED: 19786862] immune reactivity in patients undergoing lung resection.
Journal of International Medical Research 2012;40(1):141-56.
Soliman 2016 {published data only} [EMBASE: 2012137611; PUBMED: 22429354]
Soliman R, Zohry G. The myocardial protective effect
Wallace 2004 {published data only}
of dexmedetomidine in high-risk patients undergoing
aortic vascular surgery. Annals of Cardiac Anaesthesia Wallace AW, Galindez D, Salahieh A, Layug EL, Lazo EA,
2016;19(4):606-13. [MEDLINE: 27716690] Haratonik KA, et al. Effects of clonidine on cardiovascular
morbidity and mortality after noncardiac surgery.
Stuhmeier 1996 {published data only} Anesthesiology 2004;101(2):284-93. [PUBMED: 15277909]
Stuhmeier KD, Mainzer B, Cierpka J, Sandmann W, Tarnow J.
Wijeysundera 2014a {published data only}
Small, oral dose of clonidine reduces the incidence of
intraoperative myocardial ischemia in patients having vascular Wijeysundera DN, Choi PT, Badner NH, Brasher PM, Dresser GK,
surgery. Anesthesiology 1996;85(4):706-12. [PUBMED: 8873539] Delgado DH, et al. A randomized feasibility trial of clonidine to
reduce perioperative cardiac risk in patients on chronic beta-
Su 2016 {published data only} blockade: the EPIC study. Canadian Journal of Anaesthesia
Su X, Meng ZT, Wu XH, Cui F, Li HL, Wang DX, et al. 2014;61(11):995-1003. [PUBMED: 25189430]
Dexmedetomidine for prevention of delirium in elderly patients
Xu 2014 {published data only}
after non-cardiac surgery: a randomised, double-blind, placebo-
controlled trial. Lancet 2016;388(10054):1893-902. [EMBASE: Xu L, Hu Z, Shen J, McQuillan PM. Does dexmedetomidine
613271791] have a cardiac protective effect during non-cardiac surgery?
A randomised controlled trial. Clinical and Experimental
Talke 1995 {published data only} Pharmacology and Physiology 2014;41(11):879-83. [EMBASE:
Talke P, Li J, Jain U, Leung J, Drasner K, Hollenberg M, et al. 2014925423; PUBMED: 25132247]
Effects of perioperative dexmedetomidine infusion in patients
Yin 2002 {published data only}
undergoing vascular surgery. Anesthesiology 1995;82(3):620-33.
[PUBMED: 7879930] Yin YC, Chow LH, Tsao CM, Chu CC, Tsou MY, Chan KH, et al.
Oral clonidine reduces myocardial ischemia in patients with
Talke 2000 {published data only} coronary artery disease undergoing noncardiac surgery.
Talke P, Chen R, Thomas B, Aggarwall A, Gottlieb A, Thorborg P, Acta Anaesthesiologica Sinica 2002;40(4):197-203. [PUBMED:
et al. The hemodynamic and adrenergic effects of perioperative 12596619]
dexmedetomidine infusion after vascular surgery. Anesthesia
and Analgesia 2000;90(4):834-9. [PUBMED: 10735784]
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Venn 1999 {published data only} Abdalla 2003 {published data only}
* Venn RM, Bradshaw CJ, Spencer R, Brealey D, Caudwell E, Abdalla N, Soliman AH. The effects of dexmedetomidine
Naughton C, et al. Preliminary UK experience of premedication on cortisol and interleukin-6 in patients
dexmedetomidine, a novel agent for postoperative sedation undergoing major abdominal surgery. Egyptian Journal of
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Abd Aziz 2011 {published data only}
Venn RM, Hell J, Grounds RM. Respiratory effects of
Abd Aziz N, Chue MC, Yong CY, Hassan Y, Awaisu A, Hassan J, et
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post-operative cardiac surgery patients. International Journal of
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Venn RM, Bryant A, Hall GM, Grounds RM. Effects of Abdelmageed 2011 {published data only}
dexmedetomidine on adrenocortical function, and the
Abdelmageed WM, Elquesny KM, Shabana RI, Abushama HM,
cardiovascular, endocrine and inflammatory responses in post-
Nassar AM. Analgesic properties of a dexmedetomidine infusion
operative patients needing sedation in the intensive care unit.
after uvulopalatopharyngoplasty in patients with obstructive
British Journal of Anaesthesia 2001;86(5):650-6. [PUBMED:
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Abdel-Meguid 2013 {published data only}
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for fast tracking and pain control in off-pump coronary artery
Informed decisions.
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Aho M, Lehtinen A-M, Erkola O, Kallio A, Korttila K. The Amminikutty CM, Biji KP. Study comparing preemptive analgesic
effect of intravenously administered dexmedetomidine on effects of oral Gabapentin and Clonidine against placebo in
perioperative hemodynamics and isoflurane requirements in total abdominal hysterectomy under combined spinal epidural
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Aho MS, Erkola OA, Scheinin H, Lehtinen AM, Korttila KT. Effect Anvaroglu R, Kelsaka E, Sarihasan B, Demirkaya M, Ustun E,
of intravenously administered dexmedetomidine on pain Ulger F. The effect of intravenous dexmedetomidine
after laparoscopic tubal ligation. Anesthesia and Analgesia premedication on hemodynamic response during endotracheal
1991;73:112-8. [PUBMED: 1854025] intubation and extubation and postoperative analgesic
consumption. [Turkish]. Anestezi Dergisi 2008;16(4):201-5.
Aho 1992 {published data only} [EMBASE: 2009075187]
Aho M, Scheinin M, Lehtinen AM, Erkola O, Vuorinen J, Korttila K.
Intramuscularly administered dexmedetomidine attenuates Apitzsch 2000 {published data only}
hemodynamic and stress hormone responses to gynecologic Apitzsch H, Olthoff D, Thieme V, Vetter V, Wiegel M. The effects of
laparoscopy. Anesthesia and Analgesia 1992;75(6):932-9. perioperative continuous administration of mivazerol on early
[PUBMED: 1359808] postoperative haemodynamics and plasma catecholamines
after major surgery. Anasthesiologie, Intensivmedizin,
Akin 2008 {published data only} Notfallmedizin, Schmerztherapie 2000;35(8):515-22. [PUBMED:
Akin S, Aribogan A, Arslan G. Dexmedetomidine as an adjunct 10992963]
to epidural analgesia after abdominal surgery in elderly
intensive care patients: A prospective, double-blind, clinical Arain 2002 {published data only}
trial. Current Therapeutic Research - Clinical and Experimental Arain SR, Ebert TJ. The efficacy, side effects, and recovery
2008;69(1):16-28. [EMBASE: 2008152548; PUBMED: 24692779] characteristics of dexmedetomidine versus propofol when
used for intraoperative sedation. Anesthesia and Analgesia
Akkaya 2014 {published data only} 2002;95(2):461-6. [PUBMED: 12145072]
Akkaya A, Tekelioglu UY, Demirhan A, Bilgi M, Yildiz I, Apuhan T,
et al. Comparison of the effects of magnesium sulphate and Arain 2004 {published data only}
dexmedetomidine on surgical vision quality in endoscopic Arain SR, Ruehlow RM, Uhrich TD, Ebert TJ. The efficacy of
sinus surgery: Randomized clinical study. [Portuguese]. Revista dexmedetomidine versus morphine for postoperative analgesia
Brasileira de Anestesiologia 2014;64(6):406-12. [EMBASE: after major inpatient surgery. Anesthesia and Analgesia
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Aldehayat 2011 {published data only} Arora 2015 {published data only}
Aldehayat G. Intraoperative dexmedetomidine administration Arora S, Kulkarni A, Bhargava AK. Attenuation of hemodynamic
at the end of surgery prevents post anesthetic shivering. Rawal response to laryngoscopy and orotracheal intubation using
Medical Journal 2011;36(4):274-6. [EMBASE: 2011658011] intravenous clonidine. Journal of Anaesthesiology Clinical
Pharmacology 2015;31(1):110-4. [EMBASE: 2015736900;
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Aliyeva A, Gunusen I, Karaman S, Firat V. Effects of two different
doses of dexmedetomidine on intraoperative desflurane Ayoglu 2007 {published data only}
consumption, hemodynamic parameters and neuromuscular Ayoglu H, Altunkaya H, Ozer Y, Yapakci O, Cukdar G, Ozkocak I.
blockade. [Turkish]. Erciyes Tip Dergisi 2009;31(2):110-8. Does dexmedetomidine reduce the injection pain due to
[EMBASE: 2010018778] propofol and rocuronium?. European Journal of Anaesthesiology
2007;24(6):541-5. [PUBMED: 17241503]
Altan 2005 {published data only}
Altan A, Turgut N, Yildiz F, Turkmen A, Ustun H. Effects of Ayoglu 2008 {published data only}
magnesium sulphate and clonidine on propofol consumption, Ayoglu H, Yapakci O, Ugur MB, Uzun L, Altunkaya H, Ozer Y, et al.
haemodynamics and postoperative recovery. British Journal of Effectiveness of dexmedetomidine in reducing bleeding during
Anaesthesia 2005;94(4):438-41. [PUBMED: 15653705] septoplasty and tympanoplasty operations. Journal of Clinical
Anesthesia 2008;20(6):437-41. [EMBASE: 2008461522; PUBMED:
Altindis 2008 {published data only} 18929284]
Altindis NT, Karaaslan D, Peker TT, Ozmen S, Bulbul M.
Comparison of meperidine alone with meperidine plus Babu 2013 {published data only}
dexmedetomidine for postoperative patient-controlled Babu M, Verma A, Agarwal A, Tyagi C, Upadhyay M, Tripathi S.
A comparative study in the post-operative spine surgeries:
Informed decisions.
Epidural ropivacaine with dexmedetomidine and ropivacaine Bayram 2011 {published data only}
with clonidine for post-operative analgesia. Indian Journal of Bayram A, Esmaoglu A, Akin A, Baskol G, Aksu R, Bicer C, et al.
Anaesthesia 2013;57(4):371-6. [EMBASE: 2013673831; PUBMED: The effects of intraoperative infusion of dexmedetomidine on
24163451] early renal function after percutaneous nephrolithotomy. Acta
Anaesthesiologica Scandinavica 2011;55(5):539-44. [EMBASE:
Bajwa 2011 {published data only}
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Bajwa SJS, Arora V, Kaur J, Singh A, Parmar SS. Comparative
evaluation of dexmedetomidine and fentanyl for epidural Bayram 2012 {published data only}
analgesia in lower limb orthopedic surgeries. Saudi Journal of Bayram A, Altuntas R, Ulgey A, Gunes I, Akin A, Esmaoglu A, et
Anaesthesia 2011;5(4):365-70. [EMBASE: 2011640719; PUBMED: al. Comparison between dexmedetomidine and remifentanil
22144922] for controlled hypotension in patients scheduled for
tympanoplasty. Erciyes Tip Dergisi 2012;34(2):65-8. [EMBASE:
Bajwa 2012 {published data only}
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Bajwa S, Kaur J, Singh A, Parmar S, Singh G, Kulshrestha A, et
al. Attenuation of pressor response and dose sparing of opioids Beg 2001 {published data only}
and anaesthetics with pre-operative dexmedetomidine. Indian Beg AA, Saleena K, Naqeeb AJ, Dar BA, Sofi FA. Effect of oral
Journal of Anaesthesia 2012;56(2):123-8. [EMBASE: 2012406418; clonidine premedication on anxiety and sedation in patients
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a Journal of Current Clinical Medicine & Surgery 2001;8:15-7.
Bakan 2015 {published data only}
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Bakan M, Umutoglu T, Topuz U, Uysal H, Bayram M, Kadioglu H,
et al. Opioid-free total intravenous anesthesia with propofol, Beigh 2003 {published data only}
dexmedetomidine and lidocaine infusions for laparoscopic Beigh A, Naqeeb A, Khan FA. Haemodynamic and analgesic
cholecystectomy: a prospective, randomized, double-blinded effect of oral clonidine on subarachanoid block with
study. [Portuguese]. Revista Brasileira de Anestesiologia lidocaine. Journal of Anaesthesiology Clinical Pharmacology
2015;65(3):191-9. [EMBASE: 2015796275; PUBMED: 25990496] 2003;19:389-93. [EMBASE: 2005003169]
Bakhamees 2007 {published data only} Bekker 2008 {published data only}
Bakhamees HS, El-Halafawy YM, El-Kerdawy HM, Gouda NM, Bekker A, Sturaitis M, Bloom M, Moric M, Golfinos J, Parker E,
Altemyatt S. Effects of dexmedetomidine in morbidly obese et al. The effect of dexmedetomidine on perioperative
patients undergoing laparoscopic gastric bypass. Middle East hemodynamics in patients undergoing craniotomy. Anesthesia
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Bakri 2015 {published data only}
Bakri MH, Ismail EA, Ibrahim A. Comparison of Bekker 2013 {published data only}
dexmedetomidine and dexamethasone for prevention Bekker A, Haile M, Kline R, Didehvar S, Babu R, Martiniuk F, et
of postoperative nausea and vomiting after laparoscopic al. The effect of intraoperative infusion of dexmedetomidine
cholecystectomy. Korean Journal of Anesthesiology on the quality of recovery after major spinal surgery. Journal
2015;68(3):254-60. [EMBASE: 2015102998; PUBMED: 26045928] of Neurosurgical Anesthesiology 2013;25(1):16-24. [EMBASE:
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Balaraju 2013 {published data only}
Balaraju TC, Ramdas B, Thomas R, Garg A, Sreekantha, Yogish B, Benhamou 1994 {published data only}
et al. Comparative evaluation of oral clonidine and intravenous Benhamou D, Narchi P, Hamza J, Marx M, Peyrol MT, Sembeil F.
clonidine premedication in functional endoscopic sinus Addition of oral clonidine to postoperative patient-controlled
surgery. International Journal of Pharma and Bio Sciences analgesia with i.v. morphine. British Journal of Anaesthesia
2013;4(1):B587-91. [EMBASE: 2013473514] 1994;72(5):537-40. [PUBMED: 8198904]
Basar 2008 {published data only} Bernard 1991a {published data only}
Basar H, Akpinar S, Doganci N, Buyukkocak U, Kaymak C, Bernard JM, Hommeril J-L, Passuti N, Pinaud M. Postoperative
Sert O, et al. The effects of preanesthetic, single-dose analgesia by intravenous clonidine. Anesthesiology
dexmedetomidine on induction, hemodynamic, and 1991;75(4):577-82. [PUBMED: 1928767]
cardiovascular parameters. Journal of Clinical Anesthesia
2008;20(6):431-6. [EMBASE: 2008461521; PUBMED: 18929283] Bernard 1991b {published data only}
Bernard JM, Bourreli B, Hommeril JL, Pinaud M. Effects of oral
Batista 2015 {published data only}
clonidine premedication and postoperative i.v. infusion on
Batista HMT, Bezerra IMP, Abreu LC. Effect of clonidine on haemodynamic and adrenergic responses during recovery
the target dose of propofol: Bispectral index evaluation. from anaesthesia. Acta Anaesthesiologica Scandinavica
International Archives of Medicine 2015;8(1):1-9. [CENTRAL: 1991;35(1):54-9. [PUBMED: 2006600]
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Informed decisions.
Bernard 1993 {published data only} Bouslama 2013 {published data only}
Bernard JM, Hommeril JL, Legendre MP, Passuti N, Pinaud M. Bouslama A, Echehoumi H, Smairi S, Ben Jazia K. A single
Spinal or systemic analgesia after extensive spinal surgery: intravenous dose of clonidine (4 mug/kg) given before
comparison between intrathecal morphine and intravenous induction reduces postoperative nausea and vomiting in
fentanyl plus clonidine. Journal of Clinical Anesthesia patients after myomectomy under general anesthesia. European
1993;5(3):231-6. [PUBMED: 8318243] Journal of Anaesthesiology 2013;30:148. [EMBASE: 71315902]
Bernard 1994 {published data only} Bozgeyik 2014 {published data only}
Bernard JM, Lagarde D, Souron R. Balanced postoperative Bozgeyik S, Mizrak A, Kilic E, Yendi F, Ugur B. The Effects
analgesia: effect of intravenous clonidine on blood gases and of Preemptive Tramadol and Dexmedetomidine on
pharmacokinetics of intravenous fentanyl. Anesthesia and Shivering during Arthroscopy. Saudi Journal of Anaesthesia
Analgesia 1994;79(6):1126-32. [PUBMED: 7978437] 2014;8(2):238-43. [EMBASE: 2014306876; PUBMED: 24843340]
Bhanderi 2014 {published data only} Buggy 1997 {published data only}
Bhanderi D, Shah C, Shah B, Mandowara N. Comparison of iv Buggy D, Higgins P, Moran C, O'Donovan F, McCarroll M.
dexmedetomidine V/S iv clonidine In hemodynamic stability Clonidine at induction reduces shivering after general
in laparoscopic surgery. Research Journal of Pharmaceutical, anaesthesia. Canadian Journal of Anaesthesia 1997;44(3):263-7.
Biological and Chemical Sciences 2014;5(4):910-7. [EMBASE: [PUBMED: 9067044]
2014495017]
Bulow 2007 {published data only}
Bharti 2010 {published data only} Bulow NM, Barbosa NV, Rocha JB. Opioid consumption in total
Bharti N, Bala SDI, Singh G. Effect of clonidine on postoperative intravenous anesthesia is reduced with dexmedetomidine:
pain: comparison of intravenous administration versus wound a comparative study with remifentanil in gynecologic
infiltration. Anaesthesia and Intensive Care 2010;38(6):1110-1. videolaparoscopic surgery. Journal of Clinical Anesthesia
[EMBASE: 71053337] 2007;19(4):280-5. [PUBMED: 17572323]
Bharti 2013 {published data only} Bulow 2016 {published data only}
Bharti N, Dontukurthy S, Bala I, Singh G. Postoperative Bulow NMH, Colpo E, Pereira RP, Correa EFM, Waczuk EP,
analgesic effect of intravenous (i.v.) clonidine compared Duarte MF, et al. Dexmedetomidine decreases the inflammatory
with clonidine administration in wound infiltration for response to myocardial surgery under mini-cardiopulmonary
open cholecystectomy. British Journal of Anaesthesia bypass. Brazilian Journal of Medical and Biological Research
2013;111(4):656-61. [PUBMED: 23704191] 2016;49(4):e4646. [EMBASE: 20160167871; PUBMED: 26909786]
Bhattacharjee 2010 {published data only} But 2006 {published data only}
Bhattacharjee DP, Nayek SK, Dawn S, Bandopadhyay G, But AK, Ozgul U, Erdil F, Gulhas N, Toprak HI, Durmus M,
Gupta K. Effects of dexmedetomidine on haemodynamics et al. The effects of pre-operative dexmedetomidine
in patients undergoing laparoscopic cholecystectomy- infusion on hemodynamics in patients with pulmonary
A comparative study. Journal of Anaesthesiology Clinical hypertension undergoing mitral valve replacement surgery.
Pharmacology 2010;26(1):45-8. [EMBASE: 2010114400] Acta Anaesthesiologica Scandinavica 2006;50(10):1207-12.
[PUBMED: 16978159]
Bicer 2006 {published data only}
Bicer C, Esmaoglu A, Akin A, Boyaci A. Dexmedetomidine and Campagni 1999 {published data only}
meperidine prevent postanaesthetic shivering. European Campagni MA, Howie MB, White PF, McSweeney TD.
Journal of Anaesthesiology 2006;23:149-53. [PUBMED: Comparative effects of oral clonidine and intravenous esmolol
16426470] in attenuating the hemodynamic response to epinephrine
injection. Journal of Clinical Anesthesia 1999;11(3):208-15.
Bindu 2013 {published data only} [PUBMED: 10434216]
Bindu B, Pasupuleti S, Gowd UP, Gorre V, Murthy RR, Laxmi MB.
A double blind, randomized, controlled trial to study the effect Carabine 1991a {published data only}
of dexmedetomidine on hemodynamic and recovery responses Carabine UA, Milligan KR, Moore JA. Adrenergic modulation of
during tracheal extubation. Journal of Anaesthesiology Clinical preoperative anxiety: a comparison of temazepam, clonidine,
Pharmacology 2013;29(2):162-7. [EMBASE: 2013349348; and timolol. Anesthesia and Analgesia 1991;73(5):633-7.
PUBMED: 23878434] [PUBMED: 1683183]
Boldt 1996 {published data only} Carabine 1991b {published data only}
Boldt J, Rothe G, Schindler E, Doll C, Gorlach G, Hempelmann G. Carabine UA, Wright PMC, Moore J. Preanaesthetic medication
Can clonidine, enoximone, and enalaprilat help to protect with clonidine: a dose-response study. British Journal of
the myocardium against ischaemia in cardiac surgery?. Heart Anaesthesia 1991;67(1):79-83. [PUBMED: 1859765]
1996;76(3):207-13. [PUBMED: 8868976]
Informed decisions.
Carabine 1992 {published data only} Neurology and Neurosurgery 2014;14(2):87-92. [EMBASE:
Carabine UA, Allen RW, Moore J. Partial attenuation of the 2014252119]
pressor response to endotracheal intubation. A comparison
Cheung 2011 {published data only}
of the effects of intravenous clonidine and fentanyl. European
Journal of Anaesthesiology 1992;9(4):325-9. [PUBMED: 1628636] Cheung CW, Ng KF, Choi WS, Chiu WK, Aaron Ying CL, et al.
Evaluation of the analgesic efficacy of local dexmedetomidine
Caumo 2009 {published data only} application. Clinical Journal of Pain 2011;27(5):377-82.
Caumo W, Levandovski R, Hidalgo MPL. Preoperative anxiolytic [EMBASE: 2011258679; PUBMED: 21317777]
effect of melatonin and clonidine on postoperative pain and
Cheung 2014 {published data only}
morphine consumption in patients undergoing abdominal
hysterectomy: a double-blind, randomized, placebo-controlled Cheung CW, Qiu Q, Ying AC, Choi SW, Law WL, Irwin MG. The
study. Journal of Pain 2009;10(1):100-8. [EMBASE: 2009000997; effects of intra-operative dexmedetomidine on postoperative
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Ceballos 2011 {published data only}
Cho 2015 {published data only}
Ceballos Caballero M, Osorio Rodriguez G. Anesthesia
for bariatric surgery: fentanyl versus fentanyl and Cho JS, Kim HI, Lee KY, An JY, Bai SJ, Cho JY, et al. Effect of
dexmedetomidina. [Spanish]. Neurologia, Neurocirugia y intraoperative dexmedetomidine infusion on postoperative
Psiquiatria 2011;44(4):114-21. [EMBASE: 2012108220] bowel movements in patients undergoing laparoscopic
gastrectomy: a prospective, randomized, placebo-controlled
Celebi 2013 {published data only} study. Medicine 2015;94(24):e959. [PUBMED: 26091461]
Celebi N, Canbay O, Cil H, Ayaz A. Effects of dexmedetomidine
Chua 2010 {published data only}
on succinylcholine-induced myalgia in the early postoperative
period. Saudi Medical Journal 2013;34(4):369-73. [EMBASE: Chua KS, Wang FY, Hsu HT, Lua IC, Wang HM, Tsai CJ. The
2013229731; PUBMED: 23552589] effectiveness of dexmedetomidine infusion for sedating oral
cancer patients undergoing awake fibreoptic nasal intubation.
Chadha 1992 {published data only} European Journal of Anaesthesiology 2010;27(1):36-40.
Chadha R, Padmanabhan V, Joseph A, Mohandas K. Oral [EMBASE: 2010345545; PUBMED: 19550337]
clonidine pretreatment for haemodynamic stability during
Cindea 2012 {published data only}
craniotomy. Anaesthesia and Intensive Care 1992;20(3):341-4.
[PUBMED: 1524175] Cindea I, Balcan A, Samoila B, Gherghina V, Popescu R,
Iordache I. The impact of intravenous clonidine on
Chaoba 2011 {published data only} management of acute postoperative pain following colorectal
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requirements for propofol: comparison of clonidine and of supplementation of low dose intravenous dexmedetomidine
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Informed decisions.
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Harsoor S, Rani D, Lathashree S, Nethra S, Sudheesh K. Effect Ishiyama T, Kashimoto S, Oguchi T, Furuya A, Fukushima H,
of intraoperative dexmedetomidine infusion on sevoflurane Kumazawa T. Clonidine-ephedrine combination reduces pain on
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Hashemian M, Ahmadinejad M, Mohajerani SA, Mirkheshti A. dexmedetomidine premedication - an alternative to
Impact of dexmedetomidine on hemodynamic changes during midazolam-fentanyl-combination in elective hysterectomy?.
and after coronary artery bypass grafting. Annals of Cardiac Acta Anaesthesiologica Scandinavica 1994;38(3):238-43.
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Hidalgo 2005 {published data only} reduces post operative nausea and vomiting in laparoscopic
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Tempelhoff R. The effects of clonidine premedication and
Honarmand 2007 {published data only} scalp infiltration of lidocaine on hemodynamic responses to
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Perez MV, et al. Intravenous clonidine administration and
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Informed decisions.
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CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Abi-Jaoude 1993
Methods Randomized controlled trial comparing clonidine versus placebo.
Participants 24 participants undergoing CABG surgery.
Age (yr): mean (SD): clonidine group: 59 (7.5); placebo group: 56 (12).
Sex: 17 men, 7 women.
Exclusion criteria: emergency surgical procedures, LVEF < 0.5, and chronic clonidine treatment.
Interventions 1. Clonidine 5 μg/kg orally 2 hr before surgery.

2. Placebo.
Outcomes 1. MI.
2. Myocardial ischaemia (ST depression > 0.1 mV for > 3 min before CPB).
3. Hypotension (requiring drug treatment).
4. Heart failure.
Notes Funding: source not disclosed.
Declarations of interest: not stated.
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence genera- Unclear risk Not discussed.

tion (selection bias)
Allocation concealment Unclear risk Not discussed.

(selection bias)
Blinding of participants Unclear risk Authors described study as 'double-blind.' Reported use of a placebo in con-
and personnel (perfor- trol arm, and described that "management was double blind throughout the
mance bias) study period." No other details reported.
All outcomes
Blinding of outcome as- Unclear risk Not discussed.

sessment (detection bias)
All outcomes
Informed decisions.
Abi-Jaoude 1993 (Continued)
Incomplete outcome data Low risk All data reported.

(attrition bias)
All outcomes
Selective reporting (re- Low risk Outcomes reported were concordant with methods.
porting bias)
Other bias Low risk None.
Ammar 2016
Methods Randomized controlled trial comparing dexmedetomidine versus placebo.
Participants 50 ASA class II or III people scheduled for cardiac surgery using CPB.
Age (yr): mean (SD): dexmedetomidine group: 55 (7); placebo group: 59 (6).
Exclusion criteria: aged > 75 yr, LVEF < 55%, pre-existing severe LV hypertrophy, cardiomyopathies,
Grade II (pseudonormal filling) and Grade III (restrictive filling) diastolic dysfunction, preoperative AF,
pericardial disease, drug dependence, cerebrovascular diseases, use of α-2 agonists, type I diabetes
mellitus, renal disease, significant pulmonary disease and hepatic insufficiency.
Interventions 1. Dexmedetomidine initiated 5 min before CPB at 1 μg/kg IV over 15 min, followed by 0.5 μg/kg/hr until
6 hr after surgery.
2. Normal saline placebo using identical protocol.
Outcomes 1. All-cause mortality (30 days).

2. Ischaemia (acute coronary syndrome).
3. Acute stroke.
Notes Funding: Minoufiya University.
Declaration of interest: no conflict of interest.
Recruitment dates: June 2012 to February 2014.
Risk of bias
Random sequence genera- Low risk Randomization using random number table.
Allocation concealment Low risk Independent statistician assigned to perform central randomization to ensure
(selection bias) proper concealment.
Blinding of participants Low risk Participants and clinicians blinded to assignment throughout study period.
and personnel (perfor-
mance bias)
All outcomes
Blinding of outcome as- Low risk Blinded outcome assessment.

All outcomes
Informed decisions.
Ammar 2016 (Continued)

(attrition bias)
All outcomes
porting bias)
Bergese 2010
Participants 124 people undergoing elective awake fibreoptic intubation for anticipated difficult airway.
Age (yr): range 19-78.
Exclusion criteria: pregnant or lactating women, use of α-2-adrenergic agonist or antagonist within
14 days, use of opioid administered orally or IV within 1 hr or intramuscularly within 4 hr, presence of
increased intracranial pressure or cerebrospinal fluid leak, acute alcoholic intoxication, uncontrolled
seizure disorder, history of acute unstable angina, laboratory-confirmed acute MI within past 6 weeks,
HR < 50 bpm, SBP < 90 mmHg, complete heart block unless person had a pacemaker, or liver transami-
nase enzymes > 2 times upper normal limit.
Interventions 1. Dexmedetomidine 1 μg/kg loading dose IV followed by 0.7 μg/kg/hr infusion, 15 min prior to airway
topicalization until completion of awake fibreoptic intubation.
2. Placebo (normal saline) given in identical manner.
Outcomes 1. All-cause mortality.

2. Hypotension (SBP < 80 mmHg or 30% below baseline, DBP < 50 mmHg).
3. Bradycardia (< 40 bpm or 30% below baseline).
Notes Funding: Hospira, Inc.
Declarations of interest: authors received personal fees from pharmaceutical company.
Recruitment dates: 7 August 2006 to 26 January 2007 at 17 medical centres in US.
Risk of bias
Random sequence genera- Unclear risk 1:1 randomization, stratified by Mallampati and ASA classification. No details
tion (selection bias) on methods provided.
Allocation concealment High risk Authors stated randomization schedule used.

(selection bias)
Blinding of participants Unclear risk Authors described study as 'double-blind.' Reported use of placebo in control
and personnel (perfor- arm. No other details reported.
mance bias)
All outcomes

Informed decisions.
Bergese 2010 (Continued)

All outcomes
Incomplete outcome data Unclear risk 9 participants in dexmedetomidine and 11 participants in placebo group did
(attrition bias) not receive study drug because surgery was cancelled.
All outcomes
porting bias)
Chi 2016
Methods Randomized controlled trial comparing dexmedetomidine (high dose and low dose) versus placebo.
Participants 100 people undergoing OPCAB for 3-vessel disease. With 34 participants in high-dose, 33 in low-dose
and 33 in placebo groups.
Age (yr): mean (SD): high-dose: 56 (7); low-dose: 54 (7); placebo: 56 (8).
Exclusion criteria: LVEF < 40%, LV aneurysm, acute MI in 2 weeks before OPCAB surgery, AF, need for
cardiac valve replacement, associated vascular diseases, severe systemic diseases involving renal and
hepatic systems, respiratory disease (forced vital capacity < 50% of predicted values) and preoperative
left bundle-branch block.
Interventions 1. High dose: dexmedetomidine loading dose 1 μg/kg IV over 5 min prior to induction of anaesthesia,
then maintenance dose 0.6 μg/kg/hr until end of procedure.
2. Low dose: dexmedetomidine loading dose 0.6 μg/kg IV over 5 min prior to induction of anaesthesia,
then maintenance dose 0.3 μg/kg/hr until end of procedure.
3. Placebo (normal saline) delivered in same volume.
Outcomes No outcomes reported (study not included in analyses).
Notes Funding: not stated.
Declarations of interest: not stated.
Recruitment dates: June 2012 to December 2013.
Risk of bias
Random sequence genera- Low risk Computer-generated randomization sequence.


(selection bias)
Blinding of participants High risk Open-label.

mance bias)
All outcomes
Informed decisions.
Chi 2016 (Continued)
Blinding of outcome as- High risk Open-label.

All outcomes
Incomplete outcome data Unclear risk 105 participants enrolled and randomized; however, 5 excluded from analysis
(attrition bias) because of conversion to CPB (n = 3), reoperation for major bleeding within 4
All outcomes hr (n = 1) and incomplete data acquisition (n = 1). While these were a relatively
small number of participants, there was no indication that post-hoc exclusion
was planned.
porting bias)
Cho 2016
Participants 200 people scheduled for cardiac surgery with CPB.
Age (yr): mean (SD): dexmedetomidine group: 64 (12); saline group: 62 (13).
Exclusion criteria: left main coronary artery occlusion > 50%, haemodynamically significant ar-
rhythmia, LVEF < 30%, intra-aortic balloon pump or ventricular assist device, estimated GFR < 15 mL/
min/1.73 m2, use of α-2 adrenergic agonist to treat hypertension, untreated hypertension, previous ex-
posure to dexmedetomidine or history of severe allergy to drugs.
Interventions 1. Dexmedetomidine continuous infusion 0.4 μg/kg/hr IV starting immediately after anaesthetic induc-
tion and continuing for 24 hr after surgery.
2. Normal saline infused in identical manner.
Outcomes 1. All-cause mortality (in hospital).

2. Stroke (not defined).
Notes Funding: not directly stated; however, they stated no commercial associations.
Declarations of interest: no conflict of interest.
Recruitment dates: June 2013 to January 2015.
Risk of bias
Random sequence genera- Low risk Random number table used.

Allocation concealment Low risk Sealed envelopes.

(selection bias)
Blinding of participants Low risk Matched placebo and intervention, prepared by independent member of staff.
and personnel (perfor- All staff involved in direct care were blinded to allocation arm.
mance bias)
Informed decisions.
Cho 2016 (Continued)

All outcomes
Blinding of outcome as- Unclear risk Blinded outcome assessment not discussed.
All outcomes

(attrition bias)
All outcomes
porting bias)
Corbett 2005
Methods Randomized controlled trial comparing dexmedetomidine versus propofol.
Participants 89 people undergoing non-emergent CABG surgery with an expected length of intubation < 24 hr.
Age (yr): mean (SD): 63 (10.4).
Sex: 73 men, 16 women
Exclusion criteria: hypersensitivity to either drug or any component of drugs; severe hypotension im-
mediately before initiation of study drug; HR 40 bpm immediately before initiation of study drug; re-
nal insufficiency; hepatic dysfunction; requirement for continued neuromuscular blocking agents post-
operatively; requirement for epidural or spinal anaesthesia; gross obesity; history of alcohol or drug
abuse.
Participants withdrawn from study if length of intubation exceeded 48 hr.
Interventions 1. Dexmedetomidine 1 μg/kg IV loading dose then 0.4 μg/kg/hr infusion, beginning immediately after
surgery.
2. Propofol 0.2-0.7 μg/kg/hr IV infusion.

2. Supraventricular tachyarrhythmia.
Notes Funding: Society of Critical Care Medicine, Clinical Pharmacy and Pharmacology Section, Or-
tho-Biotech Fellowship Grant, and departmental funds.
Declaration of interest: not stated.
Recruitment dates: October 2002 to April 2004.
Risk of bias
Random sequence genera- Low risk Authors described use of random-number table.
Allocation concealment High risk Methods of concealment not discussed. Allocation took place in operating
(selection bias) room at end of operation.
Informed decisions.
Corbett 2005 (Continued)

mance bias)
All outcomes

All outcomes

(attrition bias)
All outcomes
Selective reporting (re- High risk Do not discuss length of intubation or ICU stay as outcomes in methods; how-
porting bias) ever, they were reported.
Devereaux 2014a
Participants 10,010 people undergoing elective non-cardiac surgery (38% orthopaedic, 27% general, 6% vascular).
Age (yr): mean (SD): clonidine group: 68.5 (10.4); placebo group: 68.6 (10.3).
Exclusion criteria: see extensive list in published protocol (Devereaux 2014b).
Interventions 1. Clonidine 0.2 mg oral dose 2-4 hr prior to surgery with placement of 0.2 mg/day transdermal patch
placed at same time and removed 72 hr after surgery.
2. Placebo (matched pill and patch).

2. Cardiac mortality.
3. MI (biochemical evidence of myocardial ischaemia and pathological changes on ECG or ECHO, or coro-
nary intervention (PCI, CABG)).
4. Heart failure (clinical signs with radiographic evidence).
5. Hypotension (SBP < 90 mmHg requiring treatment), bradycardia (HR < 55 bpm requiring treatment).
6. Stroke (new focal neurological deficit lasting > 24 hr or leading to death).
Notes Funding: grants from Canadian Institutes of Health Research, Commonwealth Government of Aus-
tralia's National Health and Medical Research Council, Spanish Ministry of Health and Social Policy,
and Boehringer Ingelheim. In this 2-by-2 factorial design trial, Bayer Pharma provided the aspirin study
drug while Boehringer Ingelheim provided the clonidine study drug.
Declarations of interest: several authors received personal fees from pharmaceutical companies but
declared that these fees had no relation or influence on the study.
Recruitment dates: July 2010 to December 2013.
Although some participants underwent surgery with only a nerve block, this accounted for < 1% of total
sample.
Risk of bias
Informed decisions.
Devereaux 2014a (Continued)
Random sequence genera- Low risk Computer-generated block randomization stratified by ASA stratum and cen-
tion (selection bias) tre.
Allocation concealment Low risk Central 24-hr randomization centre.

(selection bias)
Blinding of participants Low risk Authors reported, "Patients, health care providers, data collectors, and out-
and personnel (perfor- come adjudicators are blinded to treatment allocation." Matched placebo
mance bias) used in control arm.
All outcomes
Blinding of outcome as- Low risk Outcome adjudicators blinded. Detailed definitions of outcomes provided.
All outcomes
Incomplete outcome data Low risk Intention-to-treat analysis used and all missing data and participants account-
(attrition bias) ed for.
All outcomes
Selective reporting (re- Low risk Outcomes determined a priori and reported in a separate publication.
porting bias)
Djaiani 2016
Participants 185 participants aged > 60 yr undergoing elective complex cardiac surgery and aged > 70 yr undergo-
ing either isolated coronary revascularization or single-valve surgery (repair or replacement) with use
of CPB.
Age (yr): mean (SD): dexmedetomidine group: 73 (6.4); propofol group: 72 (6.2).
Exclusion criteria: serious mental illness, delirium, severe dementia or emergency procedures.
Interventions 1. Dexmedetomidine bolus 0.4 μg/kg IV (over 10-20 min) upon arrival on ICU, followed by 0.2-0.7 μg/kg/
hr infusion for a maximum of 24 hr.
2. Propofol infusion 25-50 μg/kg/min until readiness for tracheal extubation.
Notes Funding: funded, in part, by Hospira Inc, and Department of Anesthesia and Pain Management, Toronto
General Hospital, Toronto, Ontario, Canada.
Declaration of interest: authors declared no potential conflicts.
Recruitment dates: July 2011 to July 2014.
Risk of bias
Informed decisions.
Djaiani 2016 (Continued)
Random sequence genera- Low risk Computer-generated randomization in blocks of 4.

Allocation concealment Low risk Opaque sealed envelopes generated according to randomization schedule and
(selection bias) opened by a study co-ordinator.
Blinding of participants High risk Only participants blinded.

mance bias)
All outcomes
Blinding of outcome as- Unclear risk Unblinded outcome assessment. Unclear if it would affect outcome of death.
All outcomes
Incomplete outcome data Low risk 185 participants randomized and 183 analysed. 1 participant died in operat-
(attrition bias) ing room, and 1 participant underwent off-pump coronary revascularization
All outcomes surgery based on intraoperative decision and was excluded from analysis.
porting bias)
Dorman 1993
Participants 43 people undergoing CABG surgery.
Age (yr): mean (SD): clonidine group: 65 (2); placebo group: 61 (2).
Exclusion criteria: LVEF < 45%, LV end-diastolic pressure > 18 mmHg, or chronic clonidine exposure.
Interventions 1. Clonidine 5 μg/kg orally 90 min before surgery, then 5 μg/kg via nasogastric tube 10 min before initi-
ation of CPB.
2. Placebo suspension administered in a similar protocol.
Outcomes 1. Myocardial ischaemia (use of nitrates for ischaemic ECG changes).

2. Bradycardia (requiring intraoperative pacing).
Notes Funding: grant from Society of Cardiovascular Anesthesiologists.
Declaration of interest: not discussed.
Risk of bias
Random sequence genera- Unclear risk Authors described prospective randomization but did not describe methods.

(selection bias)
Informed decisions.
Dorman 1993 (Continued)
Blinding of participants Unclear risk Reported use of placebo in control arm but did not describe details regarding
and personnel (perfor- blinding.
mance bias)
All outcomes
Blinding of outcome as- Low risk Blinded investigator used to independently assess ST changes. Blinding for
sessment (detection bias) other outcomes not discussed.
All outcomes

(attrition bias)
All outcomes
Selective reporting (re- High risk No prespecified outcomes discussed in methods.

porting bias)
El-Kerdawy 2004
Methods Randomized controlled trial comparing dexmedetomidine versus control.
Participants 50 people undergoing OPCAB graft surgery.
Age (yr): mean (SD): dexmedetomidine group: 61 (8); control group: 62 (4).
Sex: 30 men, 22 women (error in manuscript, 2 additional participants)
Exclusion criteria: LVEF < 45%, LV end-diastolic pressure > 18 mmHg, cardiac valvular abnormality,
atrioventricular block, chronic clonidine or methyldopa treatment, or SBP < 90 mmHg.
Interventions 1. Dexmedetomidine 1 μg/kg IV loading dose then 0.15 μg/kg/hr infusion, beginning 30 min before
surgery. Infusion continued until 2 hr after extubation (maximum duration 24 hr).
2. Control group received no intervention.
Outcomes 1. Myocardial ischaemia (ST depression or elevation > 0.1 mV for > 1 min after surgery).
Notes Funding: not discussed.
Risk of bias
Random sequence genera- Unclear risk Authors stated participants randomly allocated but methods not described.

(selection bias)

mance bias)
All outcomes
Informed decisions.
El-Kerdawy 2004 (Continued)

All outcomes

(attrition bias)
All outcomes
porting bias)
Ellis 1994
Participants 61 people, with a diagnosis or risk factors of coronary artery disease, who were undergoing major non-
cardiac surgery (82% vascular)
Age (yr): median (IQR): clonidine group: 69 (61-74); placebo group: 68 (63-75).
Exclusion criteria: chronic methyldopa or clonidine therapy, serum creatinine > 30 mg/dL, planned
carotid endarterectomy surgery, planned thoracic aortic aneurysm surgery, pulse < 50 bpm, or PR inter-
val > 0.24 sec.
Interventions 1. Clonidine transdermal patch 200 μg/day for 72 hr from night before surgery. In addition, clonidine 300
μg orally 60-90 min before surgery.
2. Placebo skin patches and tablets were administered in an identical protocol.

2. MI (persistent new Q-wave on ECG, or CK-MB > 40 IU) (7 days).
3. Myocardial ischaemia (ST depression > 0.1 mV or elevation > 0.2 mV for > 1 min).
4. Heart failure.
Notes Study was terminated early at 61 participants due to low incidence of ischaemia. It was originally de-
signed to recruit 160 participants in 2 arms.
Funding: Anesthesiology Young Investigator Award from the Foundation for Anesthesia Education and
Research.
Recruitment dates: November 1990 to May 1992.
Risk of bias
Random sequence genera- Low risk Authors reported use of computer-generated random numbers.

(selection bias)
Informed decisions.
Ellis 1994 (Continued)
Blinding of participants Low risk Authors reported that all participants and clinicians were blinded to treatment
and personnel (perfor- assignment throughout study.
mance bias)
All outcomes
Blinding of outcome as- Low risk Outcome assessment by an investigator not involved in care of participant,
sessment (detection bias) blinded to allocation.
All outcomes

(attrition bias)
All outcomes
porting bias)
Other bias High risk Study terminated early because of a lower than expected rate of myocardial is-
chaemia; unclear whether this unblinded interim analysis was prespecified.
Ghignone 1986
Participants 24 people with hypertension who were NYHA class 3-4 with LVEF > 0.5 and undergoing CABG surgery.
Age (yr): mean (SD): clonidine group: 60 (9); control group: 58 (5).
Exclusion criteria: none.
Interventions 1. Clonidine 5 μg/kg orally 90 min before surgery.

2. Control group received standard treatment.
Outcomes 1. Myocardial ischaemia (assessed by changes in ST and T waves).
Risk of bias
Random sequence genera- Unclear risk Authors stated participants were randomly assigned but did not describe
tion (selection bias) methods.

(selection bias)

mance bias)
All outcomes
Blinding of outcome as- High risk Criteria for outcome assessment not prespecified. Open-label.
Informed decisions.
Ghignone 1986 (Continued)

All outcomes
Incomplete outcome data Unclear risk Inconsistency in reporting number of participants in each arm (i.e. Figure 2).
(attrition bias)
All outcomes
porting bias)
Ghignone 1987
Methods Randomized controlled trial comparing clonidine versus placebo
Participants 30 people ASA II-III with hypertension undergoing non-cardiac surgery (abdominal, head and neck, or-
thopaedic).
Exclusion criteria: severe hypertension (DBP > 110 mmHg), heart failure, chronic airway obstruction,
MI with 2 yr, active angina pectoris.

2. Control group received standard treatment.
Outcomes 1. Myocardial ischaemia (ST depression > 2 mm).

Risk of bias
Random sequence genera- Low risk Described use of random-number table.


(selection bias)

mance bias)
All outcomes
Blinding of outcome as- High risk Criteria for outcome assessment not prespecified. Open-label.
All outcomes

(attrition bias)
Informed decisions.
Ghignone 1987 (Continued)

All outcomes
porting bias)
Helbo-Hansen 1986
Methods Randomized controlled trial comparing clonidine versus control.
Sex: 36 men, 4 women
Exclusion criteria: concurrent valve replacement or aneurysmectomy planned, disseminated disease

other than essential arterial hypertension or diabetes, preoperative medication included α-adrener-
gic receptor blockers, ganglion blockers, loop-diuretics, clonidine or methyldopa, LVEF < 40%, AF, atri-
oventricular block, SBP < 80 mmHg at time of study drug administration.
Interventions 1. Clonidine 4 μg/kg IV 10 min before skin incision, 2 μg/kg IV 30 min after CPB, and 1 μg/kg IV after skin
suture.
2. Control group received isotonic saline at same time points.
Outcomes 1. All-cause mortality (1 month).

2. MI (not defined).
Notes Funding: Boehringer Ingelheim International.
Risk of bias
Random sequence genera- High risk Authors described use of 'stratified randomisation.' Stratification abandoned
tion (selection bias) for last few participants to even out groups.

(selection bias)
Blinding of participants High risk Placebo used in control arm; however, details of blinding not discussed.
mance bias)
All outcomes
Blinding of outcome as- High risk Not discussed,

All outcomes
Incomplete outcome data Low risk All data reported,

(attrition bias)
All outcomes
Informed decisions.
Helbo-Hansen 1986 (Continued)
Selective reporting (re- High risk MI and mortality not prespecified as outcomes in methods,
porting bias)
Herr 2003
Methods Randomized controlled trial comparing dexmedetomidine versus propofol. Analyses performed on in-
tention-to-treat basis.
Age (yr): mean (SD): dexmedetomidine group: 62 (10); propofol group: 62 (9).
Exclusion criteria: pregnant women, neurological condition preventing evaluation, unstable or un-
controlled diabetes, grossly obese, ejection fraction < 30%, hospitalized for drug overdose. People who
received neuromuscular block, epidural or spinal anaesthesia in postoperative period or any other fac-
tor that investigator determined would affect study data (i.e. haemodynamic instability) were discon-
tinued from study.
Interventions 1. Dexmedetomidine 1 μg/kg IV bolus, then 0.4 μg/kg/hr infusion, beginning immediately after surgery.
2. Propofol based on institutional protocols.
Outcomes 1. MI (not defined).

3. Heart failure.
4. Hypotension.
5. Bradycardia.
Notes Funding: supported by Abbot Laboratories.
Risk of bias
Random sequence genera- Low risk Authors described use of blocked randomization.

(selection bias)

mance bias)
All outcomes

All outcomes

(attrition bias)
Informed decisions.
Herr 2003 (Continued)

All outcomes
porting bias)
Jalonen 1997
Age (yr): mean (SD): dexmedetomidine group: 55 (9), placebo group: 56 (8).
Exclusion criteria: left main coronary artery stenosis > 50%, significant valvular dysfunction, severe
concurrent systemic disorders, preoperative medication with clonidine or α-methyldopa, strong sus-
ceptibility to allergic reactions, and uninterpretable results of ECG (e.g. left bundle branch block).
Interventions 1. Dexmedetomidine 50 ng/kg/min IV before surgery for 30 min, followed by 7 ng/kg/min IV intraoper-
atively.
2. Saline placebo administered in identical protocol.

2. MI (new persistent Q-waves on ECG and CK-MB > 70 U/L).
3. Myocardial ischaemia (ST depression > 0.1 mV or elevation > 0.2 mV for > 1 min).
5. Heart failure.
6. Hypotension (SBP < 80 mmHg after surgery).
7. Bradycardia (HR < 50 bpm after surgery).
Notes Funding: supported by Orion Corporation.
Recruitment dates: June 1992 to March 1993.
Risk of bias
Random sequence genera- Low risk Authors described use of permuted block randomization.

(selection bias)
and personnel (perfor- trol arm. No other details reported.
mance bias)
All outcomes
Blinding of outcome as- Unclear risk Blinded ECG interpretation but no other outcomes discussed.
Informed decisions.
Jalonen 1997 (Continued)

All outcomes

(attrition bias)
All outcomes
porting bias)
Khalil 2013
Participants 50 people undergoing OPCAB graft surgery.
Age (yr): mean (SD): dexmedetomidine group: 58.1 (10): placebo group: 58.9 (10).
Exclusion criteria: body mass index > 35 kg/m2; left main coronary artery disease; left bundle branch
block; severe combined renal, hepatic or respiratory disorders; or any contraindication to use of
dexmedetomidine. Post-hoc exclusion of people who developed severe haemodynamic alterations or
arrhythmias requiring CPB.
Interventions 1. Dexmedetomidine 1 μg/kg IV bolus over 10 min at induction, followed by a 0.5 μg/kg/hr IV infusion
until end of surgery, then a 0.25 μg/kg/hr IV infusion until arrival in ICU.
Outcomes 1. All-cause mortality (until hospital discharge, mean 6 days).
Notes Funding: reported no financial support received for research.
Declaration of interest: stated no conflict of interest.
Recruitment dates: January to September 2008.
Risk of bias
Random sequence genera- Low risk Authors reported use of a 'random number table.'
Allocation concealment High risk Concealment not discussed. Use of random number table high risk.
(selection bias)
Blinding of participants Low risk Authors described study as blinded. Intensivist and anaesthesiologist caring
and personnel (perfor- for participants were blinded. Described use of matched placebo in control
mance bias) arm. Separate members of staff responsible for managing the infusion, who
All outcomes were not involved in care of participant.
Blinding of outcome as- Low risk Blinding of outcome assessment not discussed. Outcome of all-cause mortali-
sessment (detection bias) ty low risk to be influenced.
All outcomes
Informed decisions.
Khalil 2013 (Continued)

(attrition bias)
All outcomes
Selective reporting (re- High risk Adverse event data not reported (stated as not significant).
porting bias)
Kim 2014a
Methods Randomized controlled trial comparing dexmedetomidine versus lidocaine versus combination versus
control.
Participants 153 people (40 dexmedetomidine, 36 lidocaine, 39 combined, and 38 control) under-going OPCAB. Only
participants in dexmedetomidine and control group included in meta-analyses.
Age (yr): median (IQR): dexmedetomidine group: 63 (56-68); control group: 65 (57-72).
Exclusion criteria: planned CPB and people diagnosed with arrhythmia with medication or pacemak-
er. Post-hoc exclusion of cases with unexpected conversion to CPB during surgery.
Interventions 1. Dexmedetomidine 0.3 μg/kg/hr IV starting after induction of anaesthesia and titrated within 0.3-0.7
μg/kg/hr to maintain mean blood pressure within 20% of preoperative value. Infusion was continued
until 24 hr postoperatively.
2. Lidocaine.
3. Dexmedetomidine + lidocaine.
4. Control group did not receive an infusion.
Outcomes 1. All-cause mortality (1 year).

2. Myocardial ischaemia (measured CK-MB and cTnI at 4 hr, day 1 and day 2 postoperatively; however,
threshold to define outcome not stated).
Notes Funding: no external funding.
Recruitment dates: September 2012 to August 2013.
Risk of bias
Random sequence genera- Low risk Internet-based computer-generated randomization sequence.


(selection bias)
Blinding of participants Unclear risk Anaesthesiologist not blinded to study drug. Participants and surgeon kept
and personnel (perfor- blinded; however, no placebo used in control group.
mance bias)
All outcomes
Informed decisions.
Kim 2014a (Continued)
Blinding of outcome as- High risk Data analyst blinded. No discussion of blinding of outcome assessment. Out-
sessment (detection bias) comes definition for myocardial ischaemia not discussed.
All outcomes
Incomplete outcome data Unclear risk 160 participants initially randomized, 4 participants excluded due to unexpect-
(attrition bias) ed conversion to surgery with CPB. 3 participants further excluded from analy-
All outcomes sis because there was a missing laboratory value; however, groups they were
allocated to not disclosed.
porting bias)
Lee 2013a
Methods Randomized controlled trial comparing dexmedetomidine versus remifentanil versus placebo.
Participants 85 participants (28 dexmedetomidine, 28 low-dose remifentanil, 29 placebo) ASA physical status I-II
and aged 20-65 yr, undergoing laparoscopic-assisted vaginal hysterectomy. Only dexmedetomidine
and placebo group were included in meta-analyses.
Sex: women.
Exclusion criteria: allergy to dexmedetomidine, clinically significant medical or psychiatric conditions,

pregnancy, history of alcohol or drug abuse, or opioid-containing pain or sedative medications.
Interventions 1. Dexmedetomidine 1 μg/kg IV bolus over 10 min, 15 min prior to induction, followed by 0.7 μg/kg/hr
IV infusion until surgical closure complete.
2. Remifentanil.
Outcomes 1. Mortality.
2. Hypotension (not defined).
3. Bradycardia (not defined).
Notes Funding: study supported by Wonkwang University, Iksan, South Korea.
Risk of bias
Random sequence genera- Low risk Authors reported use of a 'random number table.'
Allocation concealment High risk Concealment not discussed. Use of a random number table was high risk.
(selection bias)
Blinding of participants High risk Reported use of placebo in control group. Blinding not discussed.
mance bias)
All outcomes
Informed decisions.
Lee 2013a (Continued)
Blinding of outcome as- Unclear risk Not discussed and outcomes not defined.
All outcomes
Incomplete outcome data High risk 5 participants lost to follow-up for conversion to open surgery or re-explo-
(attrition bias) ration for postoperative bleeding. Not predefined in exclusion criteria or meth-
All outcomes ods.
porting bias)
Other bias Unclear risk Selection bias: exclusion criteria vague (i.e. "clinically significant medical or
psychiatric condition").
Li 2017
Participants 285 elderly people (age ≥ 60 yr) undergoing elective CABG or valve replacement surgery, or both.
Age (yr): mean (SD): dexmedetomidine group: 66.4 (5.4); placebo group: 67.5 (5.3).
Exclusion criteria: history of schizophrenia, epilepsy, Parkinson's disease or severe dementia; inability
to communicate because of severe visual/auditory dysfunction or language barrier; history of function-
al neurosurgery or brain injury; preoperative sick sinus syndrome, severe bradycardia (HR < 50 bpm),
second-degree or above atrioventricular block without pacemaker; severe hepatic insufficiency (Child-
Pugh grades C); severe renal insufficiency (requirement of renal replacement therapy); person refused
to participate in study.
Interventions 1. Dexmedetomidine 0.6 μg/kg bolus IV over 10 min, follow by 0.4 μg/kg/hr infusion until end of opera-
tion, and then 0.1 μg/kg/hr until end of mechanical ventilation.
2. Normal saline placebo administered in identical protocol.
Outcomes 1. All-cause mortality (30-day).

2. Acute stroke (30-day).
3. Bradycardia (requiring treatment, intraoperative or postoperative).
4. Hypotension (requiring treatment, intraoperative or postoperative).
Notes Funding: Scientific Research Fund (2015) from Peking University First Hospital. Study drugs manufac-
tured and supplied by Jiangsu Hengrui Medicine Co, Ltd, Jiangsu, China.
Declaration of interest: Dr DX Wang received lecture fees or travel expenses (or both) for lectures given
at domestic academic meetings from Jiangsu Hengrui Medicine Co, Ltd, China. Prof D Ma was support-
ed by BOC Chair grant, Royal College of Anaesthetists, and BJA Fellowship grant, London, UK. Other au-
thors reported no conflict of interests.
Recruitment: 1 December 2014 to 19 July 2015.
Risk of bias
Random sequence genera- Low risk Centre-stratified randomization with a block size of 4 using SAS statistical
tion (selection bias) package by an independent biostatistician.
Informed decisions.
Li 2017 (Continued)
Allocation concealment Low risk Randomization results sealed in sequentially numbered letters and stored at
(selection bias) site of investigation until end of study.
Blinding of participants Low risk All investigators, healthcare team members and participants blinded to treat-
and personnel (perfor- ment group assignment throughout study period. Study drugs prepared and
mance bias) coded by independent pharmacist.
All outcomes
Blinding of outcome as- Unclear risk Not formally discussed but outcomes unlikely to be influenced.
All outcomes
Incomplete outcome data Unclear risk More participants in dexmedetomidine group (8) were lost to follow-up than
(attrition bias) in control group (3), which may influence results given low frequency of out-
All outcomes comes.
porting bias)
Lipszyc 1991
Participants 40 people undergoing vascular (carotid artery) surgery.
Age: not reported.
Sex: not reported.
Exclusion criteria: not reported.

2. Placebo was given using matched oral tablets.
Outcomes 1. Myocardial ischaemia (ST depression > 0.1 mV for > 1 min).
Notes Published as an abstract.
Funding: not discussed.
Risk of bias
Random sequence genera- High risk Not described as randomized trial.

Allocation concealment High risk Not discussed.

(selection bias)
mance bias)
Informed decisions.
Lipszyc 1991 (Continued)

All outcomes

All outcomes

(attrition bias)
All outcomes
porting bias)
Other bias Unclear risk Study published as abstract and not formally peer reviewed.
Liu 2016
Participants 88 participants, aged ≥18 yr, undergoing elective cardiac surgery with CPB, admitted to ICU while intu-
bated and ventilated, and lack of prior AF or flutter before receiving sedation in ICU.
Age (yr): mean (IQR): dexmedetomidine group: 53 (46.0-63.0); propofol group: 57 (49.3-62.0).
Exclusion criteria: HR < 50 bpm, atrioventricular conduction block grade II or III (unless a pacemak-
er had been installed), MAP < 55 mmHg (despite appropriate IV volume replacement and vasopressor
treatment), acute severe neurological disorder, propofol or dexmedetomidine allergy or other con-
traindications. In addition, people who had received ≥ 2 sedatives within 24 hr postoperatively exclud-
ed.
Interventions 1. Dexmedetomidine ≤ 1.5 μg/kg/hr adjusted to maintain RASS at 0 to -3, from arrival in ICU until extu-
bation.
2. Propofol ≤ 3 mg/kg/hr adjusted to maintain RASS at 0 to -3.
Outcomes 1. Mortality (in hospital).

2. AF (no consistent P waves before each QRS complex) (96 hr).
3. Bradycardia (HR < 60 bpm for > 5 min).
4. Hypotension (MAP < 65 mmHg for > 3 min).
Notes Funding: authors stated, "not applicable."
Declaration of interest: declared no conflict of interest.
Recruitment dates: January 2015 to December 2015.
First Affiliated Hospital of Zhejiang University.
Risk of bias
Random sequence genera- Low risk Random number table used.

Informed decisions.
Liu 2016 (Continued)
Allocation concealment High risk Used random number table but no discussion of concealment.
(selection bias)

mance bias)
All outcomes

All outcomes
Incomplete outcome data Low risk Only 1 participants in each group excluded because they received sedatives.
(attrition bias)
All outcomes
Selective reporting (re- Unclear risk Mortality reported but not listed as outcome in methods.
porting bias)
Loick 1999
Methods Randomized controlled trial comparing clonidine versus thoracic epidural anaesthesia versus control.
Participants 70 people (24 clonidine, 25 epidural, 21 control) undergoing CABG surgery.
Exclusion criteria: disorders of intestine and liver, gastritis, duodenal ulcer, autonomic neuropathy,
diabetes mellitus.
Interventions 1. Clonidine 5 μg/kg orally 90 min before surgery, followed by 5 μg/kg via nasogastric tube 10 min before
initiation of CPB.
2. Thoracic epidural anaesthesia.
3. Control group received standard care.
Outcomes 1. All-cause mortality (6 months).

2. MI (troponin T > 0.1 ng/mL).
3. Myocardial ischaemia (ST depression > 0.1 mV or ST elevation > 0.2 mV).
4. Bradycardia (requiring pacing).
Notes Only participants in clonidine and control arms included in analyses.
Data on ischaemia available for only 29 participants (clonidine group: 14; control group: 15).
Risk of bias
Informed decisions.
Loick 1999 (Continued)

(selection bias)

mance bias)
All outcomes

All outcomes
Incomplete outcome data Unclear risk 2 participants in control arm excluded because of repeat thoracotomy for
(attrition bias) bleeding.
All outcomes
porting bias)
Matot 2000
Participants 36 people ASA I-III, aged ≥ 50 yr undergoing microlaryngoscopy and rigid bronchoscopy under general
anaesthesia.
Exclusion criteria: preoperative use of clonidine, HR < 50 bpm, atrioventricular block, left bun-
dle-branch block or gastrointestinal disturbance that would hinder absorption medication.
Interventions 1. Clonidine 300 μg orally 90 min prior to surgery.

2. Placebo.
Outcomes 1. Myocardial ischaemia (ST depression > 0.1 mV or elevation > 0.2 mV for > 1 min).
3. Heart failure.
Notes Funding: institutional funding.
Risk of bias
Informed decisions.
Matot 2000 (Continued)

(selection bias)
Blinding of participants Low risk Authors described use of coded oral preparations with placebo in control arm.
mance bias)
All outcomes
Blinding of outcome as- Low risk Clinician who analysed ECGs was blinded to treatment assignment. Criteria
sessment (detection bias) were prespecified to define ischaemia, hypotension and bradycardia.
All outcomes

(attrition bias)
All outcomes
porting bias)
McSPI-Europe 1997
Methods Randomized controlled trial comparing mivazerol (high and low dose) versus placebo.
Participants 317 people (17 excluded) with coronary artery disease undergoing vascular surgery under general
anaesthesia for > 1 hr.
(high-dose group: 98; low-dose group: 99; placebo: 103).
Age (yr): mean (SD): high-dose group: 67 (10); low-dose group: 65 (10); placebo group: 66 (8).
Exclusion criteria: taking methyldopa, α-2 adrenergic agonists or tricyclic antidepressants; in cardio-
genic shock and had clinical signs of heart failure or required chronic inotropic support for ventricular
dysfunction; unstable angina or uncontrolled hypertension; conduction defects that precluded electro-
cardiographic analysis of ST segments; pregnant or ASA physical status V.
Interventions 1. High-dose mivazerol 4 μg/kg IV bolus 20 min prior to induction of anaesthesia and continued as a 1.5
μg/kg/hr infusion for 72 hr after surgery.
2. Low-dose mivazerol 2 μg/kg IV bolus and 0.75 μg/kg/hr infusion.
3. Placebo.

2. Cardiac mortality.
3. MI (persistent new Q-wave or CK-MB > 100 ng/mL).
4. Myocardial ischaemia (ST depression > 0.1 mV or ST elevation > 0.2 mV for > 1 min during first 24 post-
operative hr).
5. Heart failure.
6. Bradycardia (requiring drug treatment).
Notes Mivazerol arms were combined in analyses.
Funding: grants from UCB Pharma and the Ischemia Research and Education Foundation.
Informed decisions.
McSPI-Europe 1997 (Continued)

Declaration of interest: stated no conflict of interest.
Recruitment dates: March to December 1993.
Risk of bias
Random sequence genera- Low risk Authors described use of blocked stratified randomization.

(selection bias)
Blinding of participants Low risk Authors reported use of placebo in control arm. Reported that staff who un-
and personnel (perfor- dertook clinical care were blinded to treatment assignment.
mance bias)
All outcomes
Blinding of outcome as- Low risk Authors reported that staff who interpreted ECG recordings, diagnosed MI by
sessment (detection bias) ECG criteria and performed statistical analyses were blinded to treatment as-
All outcomes signment.
Incomplete outcome data Unclear risk Excluded 7 participants for 'technical reasons,' which is ambiguous. Table 2
(attrition bias) only reported results for 98/103 participants in placebo group.
All outcomes
porting bias)
Myles 1999
Methods Randomized controlled trial comparing clonidine versus placebo
Participants 156 people (6 excluded) undergoing CABG surgery.
Exclusion criteria: receiving clonidine or alpha-methyldopa, allergic to clonidine, considered very high
risk (clinical severity score > 9), hypotensive (SBP < 120 mmHg), heart failure, ejection fraction < 25%,
AF or atrioventricular block, left bundle branch block or had a pacemaker.
Interventions 1. Clonidine 5 μg/kg orally 90 min before surgery, followed by 5 μg/kg via nasogastric tube before CPB.
2. Placebo.
Outcomes 1. All-cause mortality (1 month).

2. MI (CK-MB fraction > 5%).
3. Myocardial ischaemia (intraoperative ST depression > 0.1 mV or ST elevation > 0.2 mV for > 2 min).
4. Bradycardia (HR < 50 bpm requiring drug therapy).
5. Hypotension (mean blood pressure < 65 mmHg requiring drug therapy).
Informed decisions.
Myles 1999 (Continued)

Risk of bias
Random sequence genera- Low risk Authors described use of stratified randomization.
Allocation concealment Low risk Independent randomization by research pharmacy.

(selection bias)
Blinding of participants Low risk Authors reported use of a placebo in control arm. In addition, they described
and personnel (perfor- that "investigators and patients" were blinded to treatment assignment.
mance bias)
All outcomes
Blinding of outcome as- Low risk Diagnosis of MI by ECG and biochemical criteria was made by a blinded clini-
sessment (detection bias) cian. Statistical analyses performed by staff blinded to treatment assignment.
All outcomes
Incomplete outcome data Low risk Exclusions reported with valid explanations provided.
(attrition bias)
All outcomes
porting bias)
Oliver 1999
Methods Randomized controlled trial comparing mivazerol versus placebo. Analyses performed on intention-to-
treat basis.
Participants 2854 people with a diagnosis or risk factors for coronary artery disease who were undergoing vascular,
abdominal, thoracic or orthopaedic surgery. Results only presented for 1897 with coronary artery dis-
ease.
Age (yr): 48% aged 65-75.
Exclusion criteria: unstable angina, MI in past 14 days, uninterpretable ECG Q-waves, cardiogenic
shock, prescribed alpha-methyldopa or clonidine, severe hepatic disorders, renal insufficiency, emer-
gency surgery, pregnant or nursing women.
Interventions 1. Mivazerol 4 μg/kg IV bolus 20 min before induction of anaesthesia, and 72 hr IV infusion at 1.5 μg/kg/hr.
2. Placebo (normal saline).
Outcomes 1. All-cause mortality (30 day).

2. Cardiac cause mortality (30 days).
3. MI (persistent new Q-wave with clinical syndrome or troponin-T > 1 μg/L).
Informed decisions.
Oliver 1999 (Continued)
Notes 2857 participants were recruited in total, but only results for 1897 participants with coronary artery dis-
ease were reported.
Funding: UCB SA Pharma Sector.
Declaration of interest: State steering committee not sponsored by UCB Pharma but further potential
conflicts not stated.
Recruitment dates: June 1994 to February 1997.
Risk of bias
Random sequence genera- Low risk Authors described use of a computer-generated randomization schedule with
tion (selection bias) stratification by institution.

(selection bias)
Blinding of participants Low risk Authors described study as 'double-blind.' Reported use of a placebo in con-
and personnel (perfor- trol arm.
mance bias)
All outcomes
Blinding of outcome as- Low risk Authors reported that all outcomes were adjudicated by staff who were blind-
sessment (detection bias) ed to treatment assignment.
All outcomes
Incomplete outcome data High risk Only presented data for 1897/2854 recruited participants.
(attrition bias)
All outcomes
Selective reporting (re- High risk Reported primary outcome on participants with known coronary heart disease
porting bias) and excluded 957/2854 participants who were at risk.
Other bias High risk Adaptive study design. Study inclusion criteria were modified after monitoring
of blinded data (1304 participants recruited). Since event rates in participants
with risk factors for coronary artery disease were lower than expected, trial
protocol was amended to focus only on participants with pre-existing coro-
nary artery disease.
Park 2014
Methods Randomized controlled trial comparing dexmedetomidine versus remifentanil.
Participants 142 people undergoing open heart surgery with CPB.
Age (yr): mean (SD): dexmedetomidine group: 51 (16); remifentanil group: 54 (13).
Exclusion criteria: re-do and emergency surgery; severe pulmonary or systemic disease; LVEF < 40%;
pre-existing renal dysfunction (serum creatinine level > 2.0 mg/dL); documented preoperative demen-
tia, Parkinson's disease or recent stroke; and aged > 90 yr or < 17 yr. In addition, people who had psy-
chotropic medications, evidence of progressed heart block and surgery requiring deep hypothermic
circulatory arrest involving thoracic aorta were excluded.
Informed decisions.
Park 2014 (Continued)
Interventions 1. Dexmedetomidine loading dose 0.5 μg/kg, then maintenance dose 0.2-0.8 μg/kg/hr to maintain an
RASS of 3 (before extubation) and 2 (after extubation), from arrival in ICU until extubation.
2. Remifentanil 1000-2500 μg/hr titrated to same sedation target.
Outcomes 1. AF.
2. Stroke.
3. Bradycardia (HR < 55 bpm).
4. Systolic hypotension (SBP < 90 mmHg).
Recruitment dates: April 2012 to March 2013.
Konkuk University Medical Center.
Risk of bias
Random sequence genera- Unclear risk Stated participants randomly assigned, but no further description provided.

(selection bias)
Blinding of participants High risk Not discussed. Presumed to be open-label.

mance bias)
All outcomes
Blinding of outcome as- High risk Not discussed. Presumed to be open-label.

All outcomes

(attrition bias)
All outcomes
Selective reporting (re- Unclear risk Reported adverse events not discussed in methods.
porting bias)
Patel 2016
Methods Randomized controlled study comparing clonidine versus clonidine + ketamine versus placebo.
Participants 50 people undergoing OPCAB with stable angina and preserved myocardial function
Informed decisions.
Patel 2016 (Continued)

Exclusion criteria: diabetes mellitus, renal or liver disease, rhythm disorders, concomitant heart valve
surgery, ejection fraction < 40%, and emergency surgery.
Interventions 1. Clonidine 1 mg/kg IV 30 min before going to operating room.

2. clonidine + ketamine.
3. Placebo saline IV 30 min before going to operating room.
Outcomes 1. All-cause mortality (30 day).

2. MI.
3. Hypotension (SBP < 60 mmHg).
Notes Funding: stated no financial support for research.
Recruitment dates: January 2015 to September 2015.
Risk of bias
Random sequence genera- Low risk Computerized randomization table.


(selection bias)
Blinding of participants Unclear risk Participants, data collector and data processor kept blinded. Clinicians blind-
and personnel (perfor- ing not discussed.
mance bias)
All outcomes
Blinding of outcome as- Low risk Participants, data collector and data processor were kept blinded.
All outcomes

(attrition bias)
All outcomes
porting bias)
Pawlik 2005
Participants 30 people with a diagnosis of obstructive sleep apnoea who were undergoing head-and-neck surgery.
Informed decisions.
Pawlik 2005 (Continued)

Exclusion criteria: history of MI within 6 months, resting room air saturation < 90%, taking clonidine to
treat hypertension preoperatively.
Interventions 1. Clonidine 2 μg/kg orally on night before surgery and on morning of surgery.
2. Matched placebo given at identical times.
Outcomes 1. Myocardial ischaemia (angina requiring treatment).

2. Bradycardia (HR < 40 bpm and requirement for atropine).
Notes Funding: support from institutional departments.
Risk of bias
Random sequence genera- Low risk Authors described use of a computer program to perform randomization.

(selection bias)
mance bias)
All outcomes

All outcomes
Incomplete outcome data Unclear risk 1 participant excluded from haemodynamic analysis because of an an-
(attrition bias) giotensin-converting enzyme inhibitor overdose on postoperative ward.
All outcomes
porting bias)
Pluskwa 1991
Participants 30 people (1 excluded) undergoing vascular (carotid artery) surgery.
Exclusion criteria: unstable angina pectoris or on long-term clonidine therapy.
Interventions 1. Clonidine 300 μg orally 90 min before surgery.

2. Placebo.
Outcomes 1. MI (not defined).

Informed decisions.
Pluskwa 1991 (Continued)

2. Bradycardia (intraoperative HR < 45 bpm).
3. Hypotension (intraoperative SBP < 100 mmHg for > 3 min and requiring drug treatment).
Risk of bias
Random sequence genera- Low risk Authors described use of a random number table.

(selection bias)
Blinding of participants Low risk Authors reported study was double-blind and that matched placebo was used
and personnel (perfor- in control arm.
mance bias)
All outcomes

All outcomes
Incomplete outcome data Unclear risk 1 participant excluded after randomization when a thrombosis in carotid
(attrition bias) artery was discovered intraoperatively. 1 participant had data partially exclud-
All outcomes ed because they required reoperation.
porting bias)
Quintin 1993
Age: not reported.
Sex: not reported.
Exclusion criteria: not reported.
Interventions 1. Clonidine 2.5 μg/kg orally before induction of anaesthesia.

2. Placebo.
Outcomes 1. Myocardial ischaemia (ST deviation > 0.1 mV for > 5 min before CPB).
Notes Results of a pilot study published as a letter to editor.
Informed decisions.
Quintin 1993 (Continued)
Risk of bias
Random sequence genera- Unclear risk Authors reported allocating participants in a randomized manner but provid-
tion (selection bias) ed no further details.

(selection bias)
mance bias)
All outcomes
Blinding of outcome as- Low risk ECG changes assessed by 2 independent observers blinded to treatment arm.
All outcomes

(attrition bias)
All outcomes
porting bias)
Other bias Unclear risk Not formally peer reviewed.
Quintin 1996
Participants 24 people (3 excluded) with hypertension who were undergoing vascular (aortic) surgery.
Exclusion criteria: treatment with clonidine, gaunabenz, rilmelidine, methyldopa or reserpine.
Interventions 1. Clonidine 6 μg/kg orally 120 min before induction of anaesthesia, followed by 3 μg/kg IV infusion over
60 min after aortic declamping.
2. Placebo.

2. Cardiac-cause mortality.
3. Bradycardia (intraoperative requiring drug treatment).
4. Hypotension (intraoperative).
Notes Funding: national research foundations and Boehringer-Ingelheim.
Risk of bias
Informed decisions.
Quintin 1996 (Continued)
Random sequence genera- Unclear risk Authors reported prospective randomization but provided no further details.

(selection bias)
mance bias)
All outcomes

All outcomes
Incomplete outcome data High risk 3 participants excluded for surgical reasons (2) or inadequate data collection
(attrition bias) (1).
All outcomes
porting bias)
Ren 2013
Participants 162 people undergoing off-pump CABG surgery.
Age: mean (SD): dexmedetomidine group: 60 (4); placebo group: 58 (6).
Exclusion criteria: aged > 75 yr, ejection fraction < 40% or bradycardia based on preoperative diagno-
sis (HR < 50 bpm), preoperative history of arrhythmia, preoperative SBP < 90 mmHg, obesity, type I or
type II diabetes mellitus, drug dependence, and history of psychiatry and cerebrovascular diseases.
Interventions 1. Dexmedetomidine 0.2-0.5 μg/kg/hr IV infusion following first vascular anastomosis until stable in ICU
for 12 hr.
2. Normal saline delivered at identical rate.
Outcomes 1. All-cause mortality (72 hr post-surgery).

2. Myocardial ischaemia (ST segment elevation of 2 mm or depression of 1 mm for > 60 seconds) (72 hr
post-surgery).
3. Supraventricular tachyarrhythmia (72 hr post-surgery).
Recruitment dates: January 2010 to January 2011.
Risk of bias
Informed decisions.
Ren 2013 (Continued)
Random sequence genera- Unclear risk Authors reported allocating participants in a randomized manner but provide
tion (selection bias) no further details.

(selection bias)
Blinding of participants High risk Blinding not discussed. Reported use of matched placebo in control arm.
mance bias)
All outcomes
Blinding of outcome as- Low risk Not done; however, outcomes unlikely to be affected given predefined criteria.
All outcomes

(attrition bias)
All outcomes
porting bias)
Shehabi 2009
Methods Randomized controlled trial comparing dexmedetomidine versus morphine.
Participants 306 people aged ≥ 60 yr undergoing on-pump cardiac surgery (including CABG, valve replacement
surgery, or both).
Age (yr): median (IQR): dexmedetomidine group: 72 (66-76); morphine group: 71 (65-75).
Exclusion criteria: allergic to any of study medications, receiving other α-2 adrenergic agonists such as
clonidine or psychoactive agents other than night-time hypnotics, preoperative HR < 55 bpm or SBP <
90 mmHg (or both), bodyweight > 150 kg or a preoperative creatinine > 140 µmol/L (1.6 mg/dL) or cre-
atinine clearance < 50 mL/min (calculated by Cockcroft Gault formula). In addition, people with docu-
mented preoperative dementia, Parkinson's disease, recent seizures and unable to understand English
and thus unable to participate in delirium assessment were excluded.
Interventions 1. Dexmedetomidine 0.3 μg/kg/hr IV infusion started within 1 hr of ICU admission until removal of chest
drains or until 48 hr of ventilation, and titrated to motor activity assessment scale of 2-4 (range of
infusion 0.1-0.7 μg/kg/hr).
2. Morphine 30 μg/kg/hr IV infusion (range of infusion 10-70 μg/kg/hr).
Outcomes 1. All-cause mortality (in hospital).

2. Myocardial ischaemia (troponin rise > 3 ng/mL) (during ICU stay, mean 45 hr).
3. Supraventricular tachyarrhythmia (during ICU stay, mean 45 hr).
4. Hypotension (SBP < 90 mmHg or decrease of 20%) (during ICU stay, mean 45 hr).
5. Bradycardia (HR < 55 bpm) (during ICU stay, mean 45 hr).
6. Stroke (new persistent neurological impairment) (during ICU stay, mean 45 hr).
Informed decisions.
Shehabi 2009 (Continued)
Notes Funding: support solely from institutional or departmental (or both) sources, though study drug pro-
vided by Hospira.
Declaration of interest: authors declared no conflict of interest.
Recruitment dates: August 2004 to December 2007.
Risk of bias
Random sequence genera- Low risk Authors described use of computer-generated randomization with blocks of
tion (selection bias) 10.
Allocation concealment Low risk Centralized randomization with a research pharmacist who prepared study
(selection bias) drugs.
Blinding of participants Low risk Authors reported study was double blinded and stated "surgeons, anaes-
and personnel (perfor- thetists, and intensive care medical and nursing staff were blinded."
mance bias)
All outcomes
Blinding of outcome as- Low risk Not discussed but outcomes clearly defined and unlikely to be influenced.
All outcomes

(attrition bias)
All outcomes
porting bias)
Soliman 2016
Participants 150 people undergoing elective aortic vascular surgery (aortic aneurysm or aortobifemoral anastomo-
sis).
Exclusion criteria: acute MI, congestive heart failure, heart block, obese people or emergency.
Interventions 1. Dexmedetomidine 1 μg/kg IV over 15 min before induction, then an infusion of 0.3 μg/kg/hr to end
of procedure.
2. Normal saline in identical protocol.

2. MI (myocardial injury as a result of myocardial ischaemia and associated with ST-segment changes
and elevated troponin level).
3. Myocardial ischaemia (ischaemia of myocardium associated with ST-segment changes without eleva-
tion in troponin level).
Informed decisions.
Soliman 2016 (Continued)

4. Stroke.
5. Hypotension.
6. Bradycardia.
Notes Funding: authors stated no support.
Declaration of interest: declare no conflict of interest.
Recruitment dates: 2013-2015.
Kasr El-Aini Hospital, Cairo University, Egypt.
Risk of bias
Random sequence genera- Unclear risk "The patients classified randomly (by simple randomization)." Details not dis-
tion (selection bias) cussed.

(selection bias)
Blinding of participants Low risk "The medication was prepared by the nursing staff and given to anaesthetist
and personnel (perfor- blindly."
mance bias)
All outcomes
Blinding of outcome as- High risk Not discussed.

All outcomes
Incomplete outcome data Low risk All date reported.

(attrition bias)
All outcomes
Selective reporting (re- Unclear risk Outcomes reported were concordant with methods.
porting bias)
Stuhmeier 1996
Methods Randomized controlled trial comparing clonidine versus placebo. Analyses were performed on inten-
tion-to-treat basis.
Participants 297 people undergoing vascular surgery.
Age (yr): mean (range): overall: 64 (28-82).
Exclusion criteria: chronic myocardial ischaemia, preoperative digitalis or chronic clonidine medica-
tion, AF, bundle branch block, second degree or greater atrioventricular-nodal block on preoperative
ECG. Criteria for post hoc exclusion were transfer to another hospital within 4 days, redo surgery, an-
other surgery within 1 week, missing data.
Interventions 1. Clonidine 2 μg/kg orally 90 min before induction of anaesthesia.
Informed decisions.
Stuhmeier 1996 (Continued)

2. Placebo administered in identical protocol.
Outcomes 1. Cardiac mortality (death from dysrhythmia or heart failure).

2. MI (new persistent Q-waves on ECG, or CK-MB elevation > 40 U/L or 10%).
3. Myocardial ischaemia (intraoperative ST deviation > 0.1 mV for > 1 min).
Recruitment dates: June 1993 to December 1994.
Risk of bias
Random sequence genera- Low risk Authors described use of a random number table.

(selection bias)
Blinding of participants Low risk Authors described study as 'double-blind.' Reported use of a matched placebo
mance bias)
All outcomes
Blinding of outcome as- Low risk Clinicians who evaluated all ECG recordings were blinded to treatment assign-
sessment (detection bias) ment. No other details on blinding provided.
All outcomes
Incomplete outcome data High risk 47 participants excluded from outcome analysis (from 297 total) because
(attrition bias) of transfers to other hospitals (14) or departments (10) within 4 days after
All outcomes surgery, redo surgery required within 1 week (8), other surgery within 1 week
(8) and missing outcome data (7).
Selective reporting (re- High risk Primary and secondary outcomes of interest were not prespecified in meth-
porting bias) ods.
Su 2016
Participants 700 people aged ≥ 65 yr undergoing elective non-cardiac surgery under general anaesthesia and were
admitted to ICU after surgery.
Age (yr): mean (SD): dexmedetomidine group: 74 (7); placebo: 74 (7).
Exclusion criteria: preoperative history of schizophrenia, epilepsy, Parkinsonism or myasthenia gravis;

inability to communicate in preoperative period (coma, profound dementia or language barrier); brain
injury or neurosurgery; known preoperative LVEF < 30%, sick sinus syndrome, severe sinus bradycardia
(< 50 bpm), or second-degree or greater atrioventricular block without pacemaker; serious hepatic dys-
Informed decisions.
Su 2016 (Continued)
function (Child-Pugh class C); serious renal dysfunction (undergoing dialysis before surgery) or low like-
lihood of survival for > 24 hr.
Interventions 1. Dexmedetomidine 0.1 μg/kg/hr within 1 hr of arrival to ICU, until first postoperative day.
2. Normal saline administered in identical protocol.

2. MI (increase of troponin T concentration above hospital laboratory's MI threshold and either new Q
waves (duration ≥ 0.03 sec) or persistent changes (4 days) in ST-T segment) (30 days).
3. Stroke (persisted new focal neurological deficit and confirmed by neurological imaging) (30 days).
4. Bradycardia (HR < 55 bpm or a decrease > 20% from baseline).
5. Hypotension (SBP < 95 mmHg or a decrease > 20% from baseline).
Notes Funding: Braun Anaesthesia Scientific Research Fund and Wu Jieping Medical Foundation. A Chinese
pharmaceutical company provided drugs used in study.
Declaration of interest: several authors, including first author, received funding from pharmaceutic
companies.
Recruitment dates: 17 August 2011 to 20 November 2013.
Peking University First Hospital and Peking University Third Hospital in Beijing.
Risk of bias
Random sequence genera- Low risk "Biostatistician, who was independent of data management and statistical
tion (selection bias) analyses, generated random numbers (in a 1:1 ratio)."
Allocation concealment Low risk "The results of randomisation were sealed in sequentially numbered en-
(selection bias) velopes and stored at the site of investigation until the end of the study."
Blinding of participants Low risk Clinicians, participants and study members blinded to treatment group as-
and personnel (perfor- signment.
mance bias)
All outcomes
Blinding of outcome as- Low risk Outcome assessment blinded.

All outcomes

(attrition bias)
All outcomes
porting bias)
Talke 1995
Methods Randomized controlled trial comparing 3 dexmedetomidine arms (low, medium and high doses), and 1
placebo arm.
Informed decisions.
Talke 1995 (Continued)
Participants 25 participants, with a diagnosis or risk factors of coronary artery disease, undergoing vascular surgery.
Age (yr): mean (SD): dexmedetomidine group (combined): 65 (9); placebo group: 66 (6).
Sex: not reported.
Exclusion criteria: unstable angina, uninterpretable ECG, taking clonidine or tricyclic antidepressant
preoperatively or did not received study drug for first 24 hr postoperatively.
Interventions 1. Low-dose dexmedetomidine IV infusion intraoperatively until 48 hr after surgery with total dose 2.64
μg/kg.
2. Medium-dose dexmedetomidine IV infusion intraoperatively until 48 hr after surgery with total dose
5.31 μg/kg.
3. High-dose dexmedetomidine IV infusion intraoperatively until 48 hr after surgery with total dose 8.03
μg/kg.
4. Placebo.
Outcomes 1. All-cause mortality (period unspecified).

2. MI (elevated CK-MB levels or new Q-waves).
3. Myocardial ischaemia (S-T or T-wave changes on ECG).
7. Heart failure.
Notes Dexmedetomidine arms were combined for purpose of analyses.
Funding: support grant from Orion Corporation, a pharmaceutical company.
Risk of bias
Random sequence genera- Unclear risk Described as randomized but details not provided.

(selection bias)
mance bias)
All outcomes
Blinding of outcome as- Low risk All staff who analysed ECG recordings were blinded to treatment assignment.
sessment (detection bias) No other details of blinding reported.
All outcomes
Incomplete outcome data Unclear risk 1 participant in dexmedetomidine arm excluded because of emergent reoper-
(attrition bias) ation.
All outcomes
porting bias)
Informed decisions.
Talke 1995 (Continued)
Talke 2000
Methods Randomized controlled trial comparing dexmedetomidine versus placebo. Analyses performed on in-
tention-to-treat basis.
Participants 41 people undergoing vascular surgery.
Exclusion criteria: pregnant, taking clonidine or tricyclic antidepressants, or had second or third-de-
gree heart block.
Interventions 1. Dexmedetomidine 1.2 μg/min IV for 20 min starting 20 min prior to surgery, then 0.8 μg/min IV for 40
min, 0.35 μg/min IV for 240 min and then 0.15 μg/min IV until 48 hr postoperatively.
2. Placebo (normal saline).
Outcomes 1. All-cause mortality (48 hr postoperatively).
Notes Funding: grant from Orion Corporation, a pharmaceutical company.
Risk of bias
Random sequence genera- Low risk Authors described use of random permuted blocks with stratification by cen-
tion (selection bias) tre.

(selection bias)
mance bias)
All outcomes

All outcomes

(attrition bias)
All outcomes
porting bias)
Informed decisions.
Venn 1999
Participants 105 people (7 excluded) who had undergone cardiac (83%) and non-cardiac (17%) surgery, and needed
> 6 hr of mechanical ventilation and sedation after surgery.
Exclusion criteria: serious central nervous system trauma or undergoing neurosurgery; requirement
for neuromuscular blocking agents, epidural or spinal anaesthesia; any contraindications or allergy to
any of trial drugs; gross obesity (> 50% above ideal bodyweight); admission for a drug overdose, pri-
or enrolment in a trial with any experimental drug in last 30 days; uncontrolled diabetes and excessive
bleeding that would be likely to require reoperation.
Interventions 1. Dexmedetomidine within 1 hr of arrival in ICU as 1 μg/kg IV loading dose and a 0.2-0.7 μg/kg/hr infu-
sion for 6-24 hr.
2. Placebo (normal saline) matched and administered using identical protocol.

2. MI.
3. Myocardial ischaemia.
Notes Excluded participants receiving epidural or spinal anaesthesia.
Funding: Abbott Laboratories.
Declaration of interest: 1 author performs consultancy work for Abbott Laboratories.
Risk of bias
Random sequence genera- Unclear risk Authors described study as randomized but no other details reported.

(selection bias)
mance bias)
All outcomes

All outcomes
Incomplete outcome data Unclear risk 7 participants withdrawn from study because of reoperation for bleeding (3),
(attrition bias) bradycardia and hypotension (2), residual neuromuscular blockade (1) and
All outcomes surgeon's request (1). These participants were included in safety data.
porting bias)
Informed decisions.
Venn 1999 (Continued)
Venn 2001
Participants 20 people undergoing non-vascular non-cardiac surgery and required > 8 hr of mechanical ventilation
after surgery.
Age (yr): mean (range): dexmedetomidine group: 65 (60-77), propofol group: 67 (64-74).
Sex: not reported.
Exclusion criteria: none reported.
Interventions 1. Dexmedetomidine 2.5 μg/kg/hr IV loading dose upon arrival in ICU and 0.2-0.5 μg/kg/hr infusion.
2. Propofol 1 mg/kg IV loading dose upon arrival in ICU, and 1-3 mg/kg/hr infusion.

Notes Funding: supported in part by Abbott Laboratories, a pharmaceutical company.
Declaration of interest: 1 author performed consultancy work for Abbott Laboratories.
Risk of bias
Random sequence genera- Unclear risk Authors described study as randomized but no other details reported.

(selection bias)

mance bias)
All outcomes

All outcomes

(attrition bias)
All outcomes
porting bias)
Informed decisions.
Viviano 2012
Methods Randomized controlled trial comparing clonidine versus ropivacaine epidural versus placebo.
Participants 60 people undergoing elective lung resection.
Age (yr): median (IQR): clonidine group: 67 (61-73); saline group: 67 (50-71).
Exclusion criteria: aged < 18 yr; guardianship/conservatorship (people who were in a coma, had ad-
vanced Alzheimer's disease or had other serious illnesses or injuries); refusal to participate; pre-exist-
ing alterations of immune system or undergoing treatments or having disorders with direct influence
on immune system; pregnancy; contraindications for epidural catheter insertion; contraindications for
clonidine, ropivacaine or remifentanil treatment; previous treatment with trial drugs or drugs belong-
ing to same pharmacological group; NYHA Functional Classification ≥ class III heart failure; and MI in 8
weeks before surgery.
Interventions 1. Clonidine 150 μg IV bolus following induction of anaesthesia followed by a 20-100 μg/hr IV infusion.
2. Ropivacaine epidural.
3. Normal saline administered in identical protocol.
Outcomes 1. All-cause mortality (during hospital admission).
Notes Funding: not reported.
Declaration of interest: declare no conflict of interest.
Recruitment dates: January 2006 to May 2007.
Risk of bias
Random sequence genera- Low risk Computer-generated randomization with block size of 6.
Allocation concealment Low risk Central randomization with an independent research pharmacist preparing all
(selection bias) study drugs.
Blinding of participants Low risk Authors reported "all personnel and participants were blinded to treatment
and personnel (perfor- assignment for the duration of the study." A research pharmacist supplied
mance bias) study drugs in coded syringes.
All outcomes
Blinding of outcome as- Low risk Not discussed; however, outcome unlikely to be influenced.
All outcomes
Incomplete outcome data Unclear risk Authors stated that all randomized participants completed trial. 10/70 partici-
(attrition bias) pants included were later excluded. Participants withdrawn during operation,
All outcomes and not included in randomization which was technically not possible. 1 par-
ticipant removed as they experienced a cardiac arrest resulting in unbinding
and excluded from final analysis.
Selective reporting (re- Unclear risk Adverse events not discussed in methods but reported.
porting bias)
Informed decisions.
Wallace 2004
Methods Randomized controlled trial comparing clonidine versus placebo. Analyses performed on intention-to-
treat basis.
Participants 190 people with a diagnosis or risk factors of coronary artery disease, undergoing elective non-cardiac
surgery (26% vascular, 18% abdominal, 5% thoracic).
Sex: not reported.
Exclusion criteria: unstable angina in month prior to surgery; uninterpretable Holter ECG secondary
to left bundle-branch block, cardiac pacemaker dependency or marked resting ST-segment and T-wave
abnormalities that precluded ECG ST-segment interpretation; preoperative use of clonidine, methyl-
dopa or tricyclic antidepressants; symptomatic aortic stenosis; SBP < 100 mmHg and refusal or inabili-
ty to give informed consent.
Interventions 1. Clonidine 200 μg orally on night before surgery and on morning of surgery. 200 μg/day transdermal
patch applied on night before surgery, and removed on postoperative day 4.
2. Placebo.
Outcomes 1. All-cause 30-day mortality.

2. MI (ECG changes and CK-MB elevation).
3. Myocardial ischaemia (ST deviation > 0.1 mV for > 1 min on Holter monitoring).
4. Heart failure.
5. Hypotension (SBP < 80 mmHg).
Notes 10.5% prevalence of epidural use.
Funding: supported by a grant-in-aid from American Heart Association, Veterans Administration Mer-
it Review Funding, Ischemia Research and Education Foundation, Northern California Institute for Re-
search and Education.
Risk of bias
Random sequence genera- Low risk Authors described use of a computer-generated randomization schedule.
Allocation concealment Low risk Allocation by an independent pharmacist.

(selection bias)
mance bias)
All outcomes
Blinding of outcome as- Low risk ECG and safety data analysed by independent clinicians blinded to treatment
sessment (detection bias) arm.
All outcomes
Incomplete outcome data Unclear risk 12 participants withdrawn from study for cancellation of procedure (10), hy-
(attrition bias) potension (1) and chest pain (1).
Informed decisions.
Wallace 2004 (Continued)

All outcomes
porting bias)
Wijeysundera 2014a
Methods Randomized controlled trial comparing clonidine versus placebo. Analyses performed on intention-to-
treat basis.
Participants 168 people considered to be an intermediated to high risk of perioperative cardiac complications un-
dergoing elective non-cardiac surgery (28% vascular) with an expected hospital length of stay ≥ 48 hr
and receiving oral β-blocker therapy for ≥ 30 days prior to surgery.
Exclusion criteria: pre-existing use of α-2 adrenergic agonists, prior adverse reaction to α-2 adrenergic
agonists, decompensated heart failure, LVEF < 40%, SBP < 90 mmHg, known clinically significant aortic
stenosis and concomitant life-threatening disease likely to limit life expectancy to < 30 days.
Interventions 1. Clonidine 200 μg orally 1 hr prior to surgery and 200 μg/day transdermal patch applied which was
removed on postoperative day 4 or hospital discharge (whichever occurred earlier).
2. Placebo administered in identical protocol.

2. MI (myocardial injury with symptoms, ECG changes, PCI or new changes on ECHO).
3. Myocardial ischaemia (troponin I or T concentration exceeding threshold at which coefficient of vari-
ation for assay was 10%).
4. Hypotension (SBP < 90 mmHg necessitating study drug withdrawal or treatment).
5. Bradycardia (requiring treatment or withdrawal of study drug).
6. Heart failure.
7. Acute stroke.
Notes Funding: Heart and Stroke Foundation of Ontario and Canadian Anesthesia Research Foundation.
Declaration of interest: declared no conflicts of interest. The lead (DNW) and senior (WSB) authors of
this study were authors on this present systematic review; however, neither author was involved in pri-
mary data abstraction or quality assessment process in this review.
Recruitment dates: June 2006 to November 2007 (Toronto General Hospital), January 2008 to August
2009 (Vancouver General Hospital), September 2007 to November 2008 (Victoria Hospital).
Risk of bias
Random sequence genera- Low risk Authors reported use of computer-generated randomization schedule.
Allocation concealment Low risk Permuted blocks with varying size used and randomization lists only available
(selection bias) to research pharmacists.
Informed decisions.
Wijeysundera 2014a (Continued)
Blinding of participants Low risk Authors stated participants, clinicians and data collectors blinded to treat-
and personnel (perfor- ment assignment. Reported use of a matched placebo in control arm. Drugs
mance bias) were prepared by research pharmacists.
All outcomes
Blinding of outcome as- Low risk Authors stated data collectors and outcome adjudicators blinded to treatment
sessment (detection bias) assignment. Outcomes defined with explicit criteria.
All outcomes
Incomplete outcome data Low risk All outcomes reported. Intention-to-treat analysis used with 7% dropout (6
(attrition bias) clonidine and 4 placebo).
All outcomes
porting bias)
Xu 2014
Participants 80 participants aged 41-75 yr, ASA II-III and diagnosis of coronary heart disease undergoing elective hip
surgery with an expected duration > 2 hr.
Age (yr): mean (SD): dexmedetomidine group: 60 (5); placebo: 59 (6).
Exclusion criteria: history of hypertension, hypotension, diabetes mellitus, arrhythmia, cerebrovascu-

lar disease, severe arrhythmia, heart failure or a combination; taking non-steroidal anti-inflammatory
drugs and hormonal medications for underlying diseases; any known sensitivity to study medications
or previous anaesthetic exposure within 1 year; abnormal preoperative liver and kidney function; ab-
normal levels of cTnI, GP-BB and myocardial enzymes; and LVEF < 40%.
Interventions 1. Dexmedetomidine 1 μg/kg IV bolus over 10 min followed by a maintenance infusion of 0.2 μg/kg/hr.
2. Normal saline placebo administered in identical protocol.
Outcomes 1. MI (change in ST segment > 0.1 mV, development of a new Q wave) (24 hr).
Notes Funding: grants from National Natural Science Foundation of China, Science and Technology Agency,
Bureau of Chinese Medicine, Project of Medical Technology, Clinical Scientific Research of Medical As-
sociation and clinical scientific research fund of Chinese Medical Association.
Risk of bias
Random sequence genera- Unclear risk Quote: "This study was a prospective randomized double-blind trial." Random
tion (selection bias) sequence generation not discussed.
Allocation concealment Low risk Sealed envelopes used. Opened by anaesthesiologist not involved in care of
(selection bias) participant.
Informed decisions.
Xu 2014 (Continued)
Blinding of participants Low risk Drug prepared by separate anaesthesiologist uninvolved in participant care
and personnel (perfor- or study. Equal volume of normal saline used in control, and likely it was
mance bias) matched.
All outcomes
Blinding of outcome as- Low risk Blinded outcome adjudicator.

All outcomes

(attrition bias)
All outcomes
porting bias)
Yin 2002
Participants 60 people with coronary artery disease undergoing non-cardiac surgery (10% vascular, 50% intraperi-
toneal, 27% orthopaedic).
Exclusion criteria: physical status other than ASA III, systemic hypotension (SBP < 90 mmHg), severe
atrioventricular conduction block including second-degree Mobitz type II and third-degree AV block,
left bundle branch block, implantation of cardiac pacemaker or chronic clonidine exposure.

2. Placebo.
Outcomes 1. Myocardial ischaemia (ST deviation > 0.1 mV for > 3 min during first 24 postoperative hr).
Notes Funding: grant of National Science Council, Taiwan.
Risk of bias
Random sequence genera- Unclear risk Authors described participants being prospectively randomized but provided
tion (selection bias) no other details.

(selection bias)
Blinding of participants Low risk Authors described study as 'double-blind.' Reported use of a placebo in con-
and personnel (perfor- trol arm. Authors described that "anaesthesia providers in the study were
mance bias) blind to all research information."
All outcomes
Informed decisions.
Yin 2002 (Continued)
Blinding of outcome as- Low risk Interpretation of all ECGs was performed by staff blinded to treatment assign-
sessment (detection bias) ment.
All outcomes

(attrition bias)
All outcomes
porting bias)
AF: atrial fibrillation; ASA: American Society of Anesthesiologists; bpm: beats per minute; CABG: coronary artery bypass graft; CK-MB:
creatinine kinase - MB; CPB: cardiopulmonary bypass; cTnI: cardiac troponin I; DBP: diastolic blood pressure; ECG: electrocardiogram;
ECHO: echocardiogram; GP-BB: glycogen phosphorylase BB; GFR: glomerular filtration rate; HR: heart rate; hr: hours; ICU: intensive care
unit; IQR: interquartile range; IU: international units; IV: intravenous; LV: left ventricular; LVEF: left ventricular ejection fraction; MAP: mean
arterial pressure; MI: myocardial infarction; min: minute; n: number; NYHA: New York Heart Association; OPCAB: off-pump coronary artery
bypass; PCI: percutaneous coronary intervention; RASS: Richmond Agitation-Sedation Scale; SD: standard deviation; SBP: systolic blood
pressure; sec: second; yr: year.
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Abd Aziz 2011 Study objectives differed.
Abdalla 2003 Study objectives differed.
Abdel-Meguid 2013 Study objectives differed.
Abdelmageed 2011 Study objectives differed.
Aho 1991a Study objectives differed.
Aho 1991b Study objectives differed.
Aho 1992 Study objectives differed.
Akin 2008 Quasi-randomized trial design (participants divided into 2 groups based on order in which
they were admitted to the intensive care unit).
Akkaya 2014 Study objectives differed.
Aldehayat 2011 Study objectives differed.
Aliyeva 2009 Study objectives differed.
Altan 2005 Study objectives differed.
Altindis 2008 Study objectives differed.
Amminikutty 2015 Study objectives differed.
Anvaroglu 2008 Study objectives differed.
Informed decisions.
Apitzsch 2000 Study objectives differed.
Arain 2002 Study objectives differed.
Arain 2004 Study objectives differed.
Arora 2015 Not randomized design.
Ayoglu 2007 Study objectives differed.
Ayoglu 2008 Study objectives differed.
Babu 2013 Study objectives differed.
Bajwa 2011 Study objectives differed.
Bajwa 2012 Study objectives differed.
Bakan 2015 Study objectives differed.
Bakhamees 2007 Study objectives differed.
Bakri 2015 Study objectives differed.
Balaraju 2013 Study objectives differed.
Basar 2008 Study objectives differed.
Batista 2015 Study objectives differed.
Bayram 2011 Study objectives differed.
Bayram 2012 Study objectives differed.
Beg 2001 Study objectives differed.
Beigh 2003 Study objectives differed.
Bekker 2008 Study objectives differed.
Bekker 2013 Study objectives differed.
Benhamou 1994 Study objectives differed.
Bernard 1991a Study objectives differed.
Bernard 1991b Study objectives differed.
Bernard 1993 Study objectives differed.
Bernard 1994 Study objectives differed.
Bhanderi 2014 Study objectives differed.
Bharti 2010 Study objectives differed.
Informed decisions.
Bharti 2013 Study objectives differed.
Bhattacharjee 2010 Study objectives differed.
Bicer 2006 Study objectives differed.
Bindu 2013 Study objectives differed.
Boldt 1996 Scientific misconduct (Rasmussen 2011; Wise 2013).
Bouslama 2013 Study objectives differed.
Bozgeyik 2014 Study objectives differed.
Buggy 1997 Study objectives differed.
Bulow 2007 Study objectives differed.
Bulow 2016 Study objectives differed.
But 2006 Study objectives differed.
Campagni 1999 Study objectives differed.
Carabine 1991a Study objectives differed.
Carabine 1991b Study objectives differed.
Carabine 1992 Study objectives differed.
Caumo 2009 Study objectives differed.
Ceballos 2011 Study objectives differed.
Celebi 2013 Study objectives differed.
Chadha 1992 Study objectives differed.
Chaoba 2011 Study objectives differed.
Chaturvedi 2014 Not randomized design.
Chen 2013 Study objectives differed.
Chen 2014 Study objectives differed.
Chen 2014a Study objectives differed.
Cheung 2011 Study objectives differed.
Cheung 2014 Study objectives differed.
Cho 2015 Study objectives differed.
Chua 2010 Study objectives differed.
Informed decisions.
Cindea 2012 Study objectives differed.
Curtis 2002 Study objectives differed.
De Deyne 2000 Study objectives differed.
De Kock 1992 Study objectives differed.
De la Mora-Gonzalez 2012 Not randomized design.
Delaunay 1991 Study objectives differed.
Demirhan 2011 Study objectives differed.
Dhorigol 2010 Study objectives differed.
Dimou 2003 Study objectives differed.
Doak 1993 Study objectives differed.
Dobrydniov 1999 Study objectives differed.
Dobrydnjov 2002 Study objectives differed.
Dogan 2008 Study objectives differed.
Dorman 1997 Study objectives differed.
Durmus 2007 Study objectives differed.
Eberhart 2000 Study objectives differed.
El 2012 Not randomized design.
Elkassem 2008 Study objectives differed.
Elliott 1997 Study objectives differed.
Ellis 1998 Study objectives differed.
ElSheikh 2010 Study objectives differed.
Elvan 2008 Study objectives differed.
Engelman 1989 Study objectives differed.
Eremenko 2014a Study objectives differed.
Eremenko 2014b Not randomized design.
Erkola 1994 Study objectives differed.
Informed decisions.
Ezri 1998 Study objectives differed.
Favre 1995 Study objectives differed.
Fehr 2001 Study objectives differed.
Feld 2003 Study objectives differed.
Flacke 1987 Study objectives differed.
Frank 1999 Study objectives differed.
Frank 2000a Study objectives differed.
Frank 2000b Study objectives differed.
Frank 2002 Study objectives differed.
Galindo 2008 Study objectives differed.
Gandhi 2017 Study objectives differed.
Ganter 2005 Study objectives differed.
Gao 2012 Study objectives differed.
Garcia-Guiral 1994 Study objectives differed.
Ghatak 2010 Study objectives differed.
Ghosh 2008 Study objectives differed.
Gomez-Vazquez 2007 Study objectives differed.
Goyagi 1996 Study objectives differed.
Grottke 2003 Study objectives differed.
Grundmann 1997 Study objectives differed.
Guglielminotti 1998 Study objectives differed.
Gupta 2011a Study objectives differed.
Gupta 2011b Study objectives differed.
Gupta 2011c Study objectives differed.
Gupta 2012 Study objectives differed.
Guven 2011 Study objectives differed.
Informed decisions.
Hahm 2002 Study objectives differed.
Hall 2006 Participants did not undergo surgery.
Handa 2000 Study objectives differed.
Harsoor 2013 Study objectives differed.
Harsoor 2014 Study objectives differed.
Hashemian 2017 Study objectives differed.
Hazra 2014 Study objectives differed.
Hidalgo 2005 Study objectives differed.
Higuchi 2002 Study objectives differed.
Honarmand 2007 Study objectives differed.
Horn 1997 Study objectives differed.
Horng 2007 Study objectives differed.
Hwang 2015 Study objectives differed.
Ishiyama 2006 Study objectives differed.
Jaakola 1994 Study objectives differed.
Jabalameli 2005 Study objectives differed.
Javaherfroosh 2009 Study objectives differed.
Jeffs 2002 Study objectives differed.
Jellish 2001 Study objectives differed.
Ji 2013 Not randomized design.
Joao 2014 Study objectives differed.
Joris 1993 Study objectives differed.
Joris 1998 Study objectives differed.
Joshi 2012 Study objectives differed.
Juarez-Pichardo 2009 Study objectives differed.
Kajiyama 2009 Not randomized design.
Kalajdzija 2011 Study objectives differed.
Kang 2012 Study objectives differed.
Informed decisions.
Karaman 2013 Study objectives differed.
Karaman 2015 Study objectives differed.
Kawasaki 2014 Not randomized design.
Kaya 2010 Study objectives differed.
Kaymak 2008 Study objectives differed.
Ke 2013 Study objectives differed.
Keniya 2011 Study objectives differed.
Khafagy 2012 Study objectives differed.
Kim 2012 Study objectives differed.
Kim 2013a Study objectives differed.
Kim 2013b Study objectives differed.
Kim 2013c Study objectives differed.
Kim 2014b Not randomized design.
Korkmaz 2013 Study objectives differed.
Koyuncu 2009 Study objectives differed.
Kulka 1996 Study objectives differed.
Kumari 2012 Study objectives differed.
Lang 2011 Study objectives differed.
Lattermann 2001 Study objectives differed.
Launo 1991 Study objectives differed.
Laurito 1991 Study objectives differed.
Laurito 1993 Study objectives differed.
Lawrence 1997 Study objectives differed.
Le Guen 2014 Study objectives differed.
Lee 2012 Study objectives differed.
Lee 2013b Study objectives differed.
Informed decisions.
Leino 2011 Study objectives differed.
Levanen 1995 Study objectives differed.
Li 2010 Study objectives differed.
Li 2013 Study objectives differed.
Liu 2013 Study objectives differed.
Lu 2013 Study objectives differed.
Lyons 1997 Study objectives differed.
Ma 2013 Study objectives differed.
Mahendru 2013 Study objectives differed.
Maldonado 2009 Study objectives differed.
Malek 2009 Study objectives differed.
Malek 2010a Not randomized design.
Malek 2010b Study objectives differed.
Manne 2014 Study objectives differed.
Mannion 2005 Study objectives differed.
Marangoni 2005 Study objectives differed.
Marchal 2001 Study objectives differed.
Mariappan 2014 Study objectives differed.
Marinangeli 2002 Study objectives differed.
Martin 2003 Half the participants underwent cardiac surgery and half underwent non-cardiac surgery;
therefore, it did not meet inclusion criteria for either subgroup (cardiac surgery versus non-
cardiac surgery subgroups).
Massad 2009 Study objectives differed.
Mishra 2012 Study objectives differed.
Mizrak 2010 Study objectives differed.
Moghadam 2012 Participants were known substance abusers.
Mohamed 2012 Study objectives differed.
Informed decisions.
Mohamed 2013 Control group did not meet inclusion criteria.
Mohammadi 2007 Study objectives differed.
Mohammadi 2008 Study objectives differed.
Mousa 2013 Study objectives differed.
Muhammad 2012 Study objectives differed.
Murari Sudre 2004 Study objectives differed.
Myatra 2010 Participants did not undergo surgery.
Nader 2001 Study objectives differed.
Nader 2009 Treatment given by alternative route.
Nakagawa 2001 Study objectives differed.
Nitta 2013 Study objectives differed.
Nour El-Din 2004 Study objectives differed.
Nunez-Bacarreza 2006 Study objectives differed.
Oddby-Muhrbeck 2002 Study objectives differed.
Ohata 1999 Study objectives differed.
Ohtani 2008 Study objectives differed.
Ohtani 2011 Study objectives differed.
Okuyama 2005 Study objectives differed.
Omote 1995 Study objectives differed.
Onodera 2011 Study objectives differed.
Owen 1997 Study objectives differed.
Ozbakis 2008 Study objectives differed.
Ozkose 2006 Study objectives differed.
Panda 2012a Study objectives differed.
Panda 2012b Study objectives differed.
Pandazi 2011 Study objectives differed.
Pant 2012 Study objectives differed.
Parameswara 2012 Study objectives differed.
Informed decisions.
Paris 2009 Study objectives differed.
Park 1996 Study objectives differed.
Park 2012 Study objectives differed.
Parlow 1999 Study objectives differed.
Patel 2012 Study objectives differed.
Patil 2012 Participants did not undergo surgery.
Pestilci 2015 Study objectives differed.
Piper 1999 Study objectives differed.
Piper 2004 Study objectives differed.
Porkkala 1998 Study objectives differed.
Pouttu 1987 Study objectives differed.
Procaccini 1993 Study objectives differed.
Quintin 1990 Study objectives differed.
Quintin 1991a Study objectives differed.
Quintin 1991b Study objectives differed.
Raouf 2004 Study objectives differed.
Ray 2010 Study objectives differed.
Reddy 2013 Study objectives differed.
Richa 2008 Study objectives differed.
Rohrbach 1999 Study objectives differed.
Rosenfeld 1993 Study objectives differed.
Ruan 2011 Study objectives differed.
Rubino 2010 Study objectives differed.
Salgado 2008 Study objectives differed.
Salgado Filho 2013 Study objectives differed.
Samantaray 2012 Study objectives differed.
Sassi 2013 Study objectives differed.
Scheinin 1992 Study objectives differed.
Informed decisions.
Schlimp 2011 Study objectives differed.
Schreiberova 2008 Study objectives differed.
Segal 1991 Study objectives differed.
Selina 2011 Not randomized design.
Senses 2013 Study objectives differed.
Shams 2013 Study objectives differed.
Shin 2012 Study objectives differed.
Shin 2013 Study objectives differed.
Shrestha 2012 Study objectives differed.
Shukla 2011 Study objectives differed.
Si 2011 Study objectives differed.
Simoni 2009 Study objectives differed.
Singh 2011 Study objectives differed.
Singh 2013 Study objectives differed.
Singh Bajwa 2012 Study objectives differed.
Sitilci 2010 Study objectives differed.
Solanki 2013 Study objectives differed.
Soliman 2011 Study objectives differed.
Stapelfeldt 2005 Study objectives differed.
Stocche 2004 Study objectives differed.
Striebel 1993 Study objectives differed.
Sudar 2013 Study objectives differed.
Sulemanji 2007 Study objectives differed.
Sun 2013 Study objectives differed.
Sung 2000 Study objectives differed.
Taheri 2010 Study objectives differed.
Taittonen 1997a Study objectives differed.
Taittonen 1997b Study objectives differed.
Informed decisions.
Taittonen 1998 Study objectives differed.
Talke 1997 Study objectives differed.
Tanskanen 2006 Study objectives differed.
Techanivate 2012 Study objectives differed.
Tekin 2007 Study objectives differed.
Thomson 1998 Study objectives differed.
Toz 2010 Study objectives differed.
Traill 1993 Study objectives differed.
Triltsch 2002 Half the participants underwent cardiac surgery and half underwent non-cardiac surgery;
therefore, it did not meet inclusion criteria for either subgroup (cardiac surgery versus non-
cardiac surgery subgroups).
Tufanogullari 2008 Study objectives differed.
Turgut 2009 Study objectives differed.
Tzortzopoulou 2009 Treatment given by alternative route.
Unlugenc 2005 Study objectives differed.
Usta 2011 Study objectives differed.
Uyar 2008 Study objectives differed.
Vanderstappen 1996 Study objectives differed.
von Dossow 2006 Study objectives differed.
Vukovic 2012 Study objectives differed.
Wahlander 2005 Scientific misconduct (Anon 2013).
Wallenborn 2008 Not randomized design.
Wan 2011 Study objectives differed.
Wang 2012 Study objectives differed.
Wawrzyniak 2013 Study objectives differed.
Weilbach 2009 Study objectives differed.
Wright 1990 Study objectives differed.
Xu 2010 Study objectives differed.
Xue 2014 Not randomized design.
Informed decisions.
Yacout 2012 Study objectives differed.
Yadav 2013 Study objectives differed.
Yang 2013 Study objectives differed.
Yektaz 2011a Study objectives differed.
Yektaz 2011b Study objectives differed.
Yldrm 2012 Study objectives differed.
Yoganarasimha 2012 Study objectives differed.
Yotsui 2001 Study objectives differed.
Yu 2003 Study objectives differed.
Zalunardo 2000 Study objectives differed.
Zhang 2013a Study objectives differed.
Zhang 2013b Study objectives differed.
Zhou 2011 Study objectives differed.
DATA AND ANALYSES
Comparison 1. Alpha-2 adrenergic agonists versus control in non-cardiac surgery
Outcome or subgroup No. of studies No. of partici- Statistical method Effect size
title pants
1 All-cause mortality 16 14081 Risk Ratio (M-H, Fixed, 95% CI) 0.80 [0.61, 1.04]
2 Cardiac mortality 5 12525 Risk Ratio (M-H, Fixed, 95% CI) 0.86 [0.60, 1.23]
3 Myocardial infarction 12 13907 Risk Ratio (M-H, Random, 95% CI) 0.94 [0.69, 1.27]
4 Myocardial ischaemia 12 1379 Risk Ratio (M-H, Random, 95% CI) 0.73 [0.53, 1.02]
5 Supraventricular tach- 2 44 Risk Ratio (M-H, Fixed, 95% CI) 1.11 [0.05, 24.07]
yarrhythmia
6 Heart failure 8 10802 Risk Ratio (M-H, Fixed, 95% CI) 1.21 [0.83, 1.75]
7 Acute stroke 7 11542 Risk Ratio (M-H, Fixed, 95% CI) 0.93 [0.55, 1.56]
Informed decisions.
title pants
8 Bradycardia 16 14035 Risk Ratio (M-H, Random, 95% CI) 1.59 [1.18, 2.13]
9 Hypotension 15 13738 Risk Ratio (M-H, Random, 95% CI) 1.24 [1.03, 1.48]
Analysis 1.1. Comparison 1 Alpha-2 adrenergic agonists versus

control in non-cardiac surgery, Outcome 1 All-cause mortality.
Study or subgroup Alpha-2 adren- Control Risk Ratio Weight Risk Ratio
ergic agonists
n/N n/N M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Bergese 2010 0/55 0/50 Not estimable
Devereaux 2014a 64/5009 63/5001 52.79% 1.01[0.72,1.43]
Ellis 1994 0/30 1/31 1.24% 0.34[0.01,8.13]
Lee 2013a 0/28 0/29 Not estimable
McSPI-Europe 1997 4/197 1/103 1.1% 2.09[0.24,18.47]
Oliver 1999 22/956 34/941 28.69% 0.64[0.38,1.08]
Quintin 1996 0/11 1/10 1.31% 0.31[0.01,6.74]
Soliman 2016 0/75 1/75 1.26% 0.33[0.01,8.05]
Stuhmeier 1996 1/145 2/152 1.64% 0.52[0.05,5.72]
Su 2016 1/350 4/350 3.35% 0.25[0.03,2.23]
Talke 1995 0/18 0/6 Not estimable
Talke 2000 0/22 1/19 1.34% 0.29[0.01,6.72]
Venn 2001 2/10 1/10 0.84% 2[0.21,18.69]
Viviano 2012 0/20 0/20 Not estimable
Wallace 2004 1/125 4/65 4.41% 0.13[0.01,1.14]
Wijeysundera 2014a 0/82 2/86 2.04% 0.21[0.01,4.3]
Total (95% CI) 7133 6948 100% 0.8[0.61,1.04]

Total events: 95 (Alpha-2 adrenergic agonists), 115 (Control)
Heterogeneity: Tau2=0; Chi2=9.9, df=11(P=0.54); I2=0%
Test for overall effect: Z=1.64(P=0.1)
Favours treatment 0.005 0.1 1 10 200 Favours control

control in non-cardiac surgery, Outcome 2 Cardiac mortality.
ergic agonists
Devereaux 2014a 38/5009 32/5001 51.72% 1.19[0.74,1.89]
McSPI-Europe 1997 1/197 1/103 2.12% 0.52[0.03,8.27]
Oliver 1999 13/956 25/941 40.69% 0.51[0.26,0.99]
Quintin 1996 0/10 1/11 2.32% 0.36[0.02,8.03]
Stuhmeier 1996 1/145 2/152 3.15% 0.52[0.05,5.72]
Total (95% CI) 6317 6208 100% 0.86[0.6,1.23]
Informed decisions.
ergic agonists
Heterogeneity: Tau2=0; Chi2=4.74, df=4(P=0.32); I2=15.56%

control in non-cardiac surgery, Outcome 3 Myocardial infarction.
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H, Random, 95% CI M-H, Random, 95% CI
Devereaux 2014a 329/5009 295/5001 41.71% 1.11[0.96,1.3]
Ellis 1994 0/30 2/31 1.02% 0.21[0.01,4.13]
McSPI-Europe 1997 3/197 6/103 4.54% 0.26[0.07,1.02]
Oliver 1999 78/956 79/941 32.17% 0.97[0.72,1.31]
Pluskwa 1991 0/15 0/15 Not estimable
Soliman 2016 1/75 3/75 1.79% 0.33[0.04,3.13]
Stuhmeier 1996 0/145 4/152 1.08% 0.12[0.01,2.14]
Su 2016 5/350 8/350 6.56% 0.63[0.21,1.89]
Wallace 2004 2/125 2/65 2.37% 0.52[0.07,3.61]
Wijeysundera 2014a 12/82 6/86 8.75% 2.1[0.83,5.33]
Xu 2014 0/40 0/40 Not estimable
Total (95% CI) 7042 6865 100% 0.94[0.69,1.27]

Total events: 430 (Treatment), 405 (Control)
Heterogeneity: Tau2=0.05; Chi2=12.61, df=8(P=0.13); I2=36.57%

control in non-cardiac surgery, Outcome 4 Myocardial ischaemia.
ergic agonists
Ellis 1994 7/28 8/26 8.89% 0.81[0.34,1.92]
Ghignone 1987 0/15 2/15 1.18% 0.2[0.01,3.85]
Lipszyc 1991 8/20 5/20 8.1% 1.6[0.63,4.05]
Matot 2000 0/18 2/18 1.17% 0.2[0.01,3.89]
McSPI-Europe 1997 35/197 16/103 14.06% 1.14[0.67,1.97]
Pawlik 2005 0/15 1/15 1.06% 0.33[0.01,7.58]
Soliman 2016 3/75 14/75 5.64% 0.21[0.06,0.72]
Stuhmeier 1996 35/145 59/152 18.01% 0.62[0.44,0.88]
Talke 1995 11/18 3/6 8.66% 1.22[0.51,2.95]
Wallace 2004 18/125 20/65 13.66% 0.47[0.27,0.82]
Wijeysundera 2014a 15/82 12/86 11.27% 1.31[0.65,2.63]
Informed decisions.
ergic agonists
Yin 2002 5/30 12/30 8.29% 0.42[0.17,1.04]
Total (95% CI) 768 611 100% 0.73[0.53,1.02]

Analysis 1.5. Comparison 1 Alpha-2 adrenergic agonists versus control

in non-cardiac surgery, Outcome 5 Supraventricular tachyarrhythmia.
ergic agonists
Talke 1995 1/18 0/6 100% 1.11[0.05,24.07]
Venn 2001 0/10 0/10 Not estimable
Total (95% CI) 28 16 100% 1.11[0.05,24.07]

Heterogeneity: Not applicable
Analysis 1.6. Comparison 1 Alpha-2 adrenergic agonists

versus control in non-cardiac surgery, Outcome 6 Heart failure.
ergic agonists
Devereaux 2014a 48/5009 34/5001 69.57% 1.41[0.91,2.18]
Ellis 1994 4/28 5/26 10.6% 0.74[0.22,2.47]
Matot 2000 0/18 0/18 Not estimable
McSPI-Europe 1997 4/197 3/103 8.06% 0.7[0.16,3.06]
Talke 1995 2/18 1/6 3.07% 0.67[0.07,6.11]
Wallace 2004 0/125 2/65 6.71% 0.1[0.01,2.15]
Wijeysundera 2014a 3/82 1/86 2% 3.15[0.33,29.64]
Total (95% CI) 5487 5315 100% 1.21[0.83,1.75]

Informed decisions.

versus control in non-cardiac surgery, Outcome 7 Acute stroke.
ergic agonists
Devereaux 2014a 18/5009 17/5001 58.53% 1.06[0.55,2.05]
McSPI-Europe 1997 10/197 5/103 22.59% 1.05[0.37,2.98]
Soliman 2016 0/75 0/75 Not estimable
Su 2016 0/350 3/350 12.04% 0.14[0.01,2.76]
Talke 1995 1/16 1/8 4.59% 0.5[0.04,7]
Wallace 2004 1/125 0/65 2.26% 1.57[0.06,38.04]
Wijeysundera 2014a 0/82 0/86 Not estimable
Total (95% CI) 5854 5688 100% 0.93[0.55,1.56]


versus control in non-cardiac surgery, Outcome 8 Bradycardia.
ergic agonists
Bergese 2010 4/55 0/50 0.99% 8.2[0.45,148.52]
Devereaux 2014a 600/5009 403/5001 22.94% 1.49[1.32,1.68]
Lee 2013a 11/28 4/29 6.18% 2.85[1.03,7.9]
McSPI-Europe 1997 64/197 36/103 18.31% 0.93[0.67,1.29]
Oliver 1999 81/956 36/941 17.01% 2.21[1.51,3.25]
Pawlik 2005 2/15 0/15 0.95% 5[0.26,96.13]
Pluskwa 1991 7/15 4/15 6.37% 1.75[0.64,4.75]
Quintin 1996 2/11 2/10 2.5% 0.91[0.16,5.3]
Soliman 2016 9/75 2/75 3.32% 4.5[1.01,20.13]
Stuhmeier 1996 23/145 30/152 14.29% 0.8[0.49,1.32]
Su 2016 5/350 1/350 1.75% 5[0.59,42.58]
Talke 1995 8/18 0/6 1.12% 6.26[0.41,94.82]
Wallace 2004 12/125 2/65 3.45% 3.12[0.72,13.52]
Wijeysundera 2014a 1/82 0/86 0.82% 3.14[0.13,76.11]
Total (95% CI) 7109 6926 100% 1.59[1.18,2.13]

Test for overall effect: Z=3.08(P=0)
Informed decisions.

versus control in non-cardiac surgery, Outcome 9 Hypotension.
ergic agonists
Bergese 2010 15/55 3/50 2.14% 4.55[1.4,14.78]
Devereaux 2014a 2385/5009 1854/5001 24.64% 1.28[1.23,1.35]
Ghignone 1987 1/15 3/15 0.69% 0.33[0.04,2.85]
Lee 2013a 10/28 3/29 2.14% 3.45[1.06,11.25]
Matot 2000 2/18 0/18 0.36% 5[0.26,97.37]
McSPI-Europe 1997 127/197 72/103 20.77% 0.92[0.78,1.09]
Oliver 1999 62/956 57/941 12.97% 1.07[0.76,1.52]
Pluskwa 1991 12/15 8/15 7.79% 1.5[0.88,2.57]
Quintin 1996 5/11 2/10 1.56% 2.27[0.56,9.2]
Soliman 2016 7/75 3/75 1.76% 2.33[0.63,8.68]
Su 2016 34/350 32/350 9.55% 1.06[0.67,1.68]
Talke 1995 17/18 4/6 7.04% 1.42[0.8,2.52]
Wallace 2004 24/125 11/65 5.93% 1.13[0.59,2.17]
Wijeysundera 2014a 7/82 6/86 2.65% 1.22[0.43,3.49]
Total (95% CI) 6964 6774 100% 1.24[1.03,1.48]

Comparison 2. Alpha-2 adrenergic agonists versus control in cardiac surgery
title pants
2 Myocardial infarction 8 782 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.43, 2.40]
3 Myocardial ischaemia 13 1134 Risk Ratio (M-H, Fixed, 95% CI) 0.69 [0.56, 0.86]
yarrhythmia
7 Bradycardia 10 1477 Risk Ratio (M-H, Fixed, 95% CI) 1.88 [1.35, 2.62]
Informed decisions.

control in cardiac surgery, Outcome 1 All-cause mortality.
ergic agonists
Ammar 2016 0/25 0/25 Not estimable
Cho 2016 1/100 5/100 21.73% 0.2[0.02,1.68]
Corbett 2005 1/43 0/46 2.1% 3.2[0.13,76.6]
Djaiani 2016 1/91 0/92 2.16% 3.03[0.13,73.48]
Helbo-Hansen 1986 0/20 0/20 Not estimable
Jalonen 1997 0/40 0/40 Not estimable
Khalil 2013 0/25 0/25 Not estimable
Kim 2014a 0/40 1/38 6.68% 0.32[0.01,7.55]
Li 2017 2/142 4/143 17.32% 0.5[0.09,2.71]
Liu 2016 0/44 1/44 6.52% 0.33[0.01,7.97]
Loick 1999 1/24 0/21 2.31% 2.64[0.11,61.54]
Myles 1999 0/76 2/74 11.01% 0.19[0.01,3.99]
Patel 2016 0/25 0/25 Not estimable
Ren 2013 0/81 0/81 Not estimable
Shehabi 2009 2/152 4/147 17.67% 0.48[0.09,2.6]
Venn 1999 1/47 3/51 12.5% 0.36[0.04,3.36]
Total (95% CI) 975 972 100% 0.52[0.26,1.04]


control in cardiac surgery, Outcome 2 Myocardial infarction.
ergic agonists
Abi-Jaoude 1993 1/11 0/13 4.65% 3.5[0.16,78.19]
Helbo-Hansen 1986 1/20 1/20 10.08% 1[0.07,14.9]
Herr 2003 3/148 1/147 10.12% 2.98[0.31,28.32]
Jalonen 1997 2/40 3/40 30.25% 0.67[0.12,3.78]
Loick 1999 1/24 0/21 5.36% 2.64[0.11,61.54]
Myles 1999 0/76 1/74 15.33% 0.32[0.01,7.84]
Venn 1999 0/47 2/51 24.2% 0.22[0.01,4.4]
Total (95% CI) 391 391 100% 1.01[0.43,2.4]

Informed decisions.

control in cardiac surgery, Outcome 3 Myocardial ischaemia.
ergic agonists
Abi-Jaoude 1993 2/11 3/13 1.91% 0.79[0.16,3.9]
Ammar 2016 1/25 1/25 0.69% 1[0.07,15.12]
Dorman 1993 8/22 13/21 9.23% 0.59[0.31,1.12]
El-Kerdawy 2004 0/25 7/25 5.21% 0.07[0,1.11]
Ghignone 1986 0/12 0/12 Not estimable
Jalonen 1997 14/40 19/40 13.19% 0.74[0.43,1.26]
Kim 2014a 1/40 1/38 0.71% 0.95[0.06,14.65]
Loick 1999 6/14 11/15 7.37% 0.58[0.3,1.15]
Myles 1999 15/76 22/74 15.47% 0.66[0.37,1.18]
Quintin 1993 3/13 6/13 4.16% 0.5[0.16,1.58]
Ren 2013 6/81 15/81 10.41% 0.4[0.16,0.98]
Shehabi 2009 35/152 35/147 24.7% 0.97[0.64,1.46]
Venn 1999 10/66 9/53 6.93% 0.89[0.39,2.04]
Total (95% CI) 577 557 100% 0.69[0.56,0.86]


in cardiac surgery, Outcome 4 Supraventricular tachyarrhythmia.
ergic agonists
Corbett 2005 1/43 0/46 1.07% 3.2[0.13,76.6]
Herr 2003 12/148 12/147 26.67% 0.99[0.46,2.14]
Jalonen 1997 9/40 10/40 22.15% 0.9[0.41,1.98]
Ren 2013 2/81 12/81 26.58% 0.17[0.04,0.72]
Shehabi 2009 3/152 5/147 11.26% 0.58[0.14,2.38]
Venn 1999 8/66 5/53 12.28% 1.28[0.45,3.7]
Total (95% CI) 530 514 100% 0.77[0.5,1.16]

Informed decisions.
Analysis 2.5. Comparison 2 Alpha-2 adrenergic agonists versus control in cardiac surgery, Outcome 5 Heart failure.
ergic agonists
Abi-Jaoude 1993 2/11 1/13 4.56% 2.36[0.25,22.7]
Herr 2003 3/148 4/147 19.98% 0.74[0.17,3.27]
Jalonen 1997 1/40 3/40 14.93% 0.33[0.04,3.07]
Myles 1999 12/76 12/74 60.53% 0.97[0.47,2.03]
Total (95% CI) 275 274 100% 0.9[0.49,1.63]

Analysis 2.6. Comparison 2 Alpha-2 adrenergic agonists versus control in cardiac surgery, Outcome 6 Acute stroke.
ergic agonists
Cho 2016 0/100 4/100 27.7% 0.11[0.01,2.04]
Jalonen 1997 0/40 1/40 9.23% 0.33[0.01,7.95]
Li 2017 3/142 3/143 18.4% 1.01[0.21,4.91]
Park 2014 0/67 2/75 14.54% 0.22[0.01,4.57]
Shehabi 2009 1/152 1/147 6.26% 0.97[0.06,15.32]
Venn 1999 0/66 3/53 23.86% 0.12[0.01,2.18]
Total (95% CI) 592 583 100% 0.37[0.15,0.93]

Analysis 2.7. Comparison 2 Alpha-2 adrenergic agonists versus control in cardiac surgery, Outcome 7 Bradycardia.
ergic agonists
Dorman 1993 7/22 5/21 10.77% 1.34[0.5,3.56]
Herr 2003 5/148 2/147 4.23% 2.48[0.49,12.6]
Jalonen 1997 4/40 1/40 2.11% 4[0.47,34.24]
Li 2017 22/142 16/143 33.57% 1.38[0.76,2.52]
Liu 2016 4/44 1/44 2.11% 4[0.47,34.38]
Loick 1999 2/24 3/21 6.74% 0.58[0.11,3.16]
Myles 1999 9/76 2/74 4.27% 4.38[0.98,19.6]
Park 2014 10/67 8/75 15.9% 1.4[0.59,3.34]
Patel 2016 1/25 0/25 1.05% 3[0.13,70.3]
Shehabi 2009 25/152 9/147 19.27% 2.69[1.3,5.56]
Informed decisions.
ergic agonists
Total (95% CI) 740 737 100% 1.88[1.35,2.62]

Analysis 2.8. Comparison 2 Alpha-2 adrenergic agonists versus control in cardiac surgery, Outcome 8 Hypotension.
ergic agonists
Abi-Jaoude 1993 10/11 6/13 11.34% 1.97[1.06,3.65]
Herr 2003 36/148 24/147 13.87% 1.49[0.94,2.37]
Jalonen 1997 13/40 8/40 9.25% 1.63[0.76,3.49]
Li 2017 120/142 100/143 18.95% 1.21[1.06,1.37]
Liu 2016 25/44 13/44 12.83% 1.92[1.14,3.25]
Myles 1999 6/76 2/74 3.44% 2.92[0.61,14.01]
Park 2014 12/67 22/75 11.26% 0.61[0.33,1.14]
Patel 2016 2/25 4/25 3.31% 0.5[0.1,2.49]
Shehabi 2009 35/152 56/147 15.74% 0.6[0.42,0.86]
Total (95% CI) 705 708 100% 1.19[0.87,1.64]

Heterogeneity: Tau2=0.14; Chi2=28.83, df=8(P=0); I2=72.25%
Comparison 3. Alpha-2 adrenergic agonists versus control in non-cardiac surgery - stratified by vascular versus non-
vascular surgery
Outcome or subgroup ti- No. of studies No. of partici- Statistical method Effect size
tle pants
1.1 Vascular surgery 8 1798 Risk Ratio (M-H, Fixed, 95% CI) 0.46 [0.25, 0.88]
1.2 Non-vascular surgery 6 1915 Risk Ratio (M-H, Fixed, 95% CI) 0.88 [0.46, 1.67]
2.1 Vascular surgery 4 1522 Risk Ratio (M-H, Fixed, 95% CI) 0.36 [0.16, 0.79]
2.2 Non-vascular surgery 1 993 Risk Ratio (M-H, Fixed, 95% CI) 0.98 [0.35, 2.77]
Informed decisions.
tle pants
3.1 Vascular surgery 7 1766 Risk Ratio (M-H, Random, 95% CI) 0.52 [0.27, 1.00]
3.2 Non-vascular surgery 3 1773 Risk Ratio (M-H, Random, 95% CI) 1.09 [0.55, 2.15]
4.1 Vascular surgery 6 865 Risk Ratio (M-H, Random, 95% CI) 0.83 [0.54, 1.29]
4.2 Non-vascular surgery 3 96 Risk Ratio (M-H, Random, 95% CI) 0.23 [0.04, 1.34]
Analysis 3.1. Comparison 3 Alpha-2 adrenergic agonists versus control in non-cardiac

surgery - stratified by vascular versus non-vascular surgery, Outcome 1 All-cause mortality.
ergic agonists
3.1.1 Vascular surgery
Ellis 1994 0/30 1/31 3.03% 0.34[0.01,8.13]
McSPI-Europe 1997 4/197 1/103 2.7% 2.09[0.24,18.47]
Oliver 1999 8/454 20/450 41.29% 0.4[0.18,0.89]
Quintin 1996 0/11 1/10 3.22% 0.31[0.01,6.74]
Soliman 2016 0/75 1/75 3.08% 0.33[0.01,8.05]
Stuhmeier 1996 1/145 2/152 4.01% 0.52[0.05,5.72]
Talke 2000 0/22 1/19 3.3% 0.29[0.01,6.72]
Subtotal (95% CI) 952 846 60.63% 0.46[0.25,0.88]
3.1.2 Non-vascular surgery

Oliver 1999 14/502 14/491 29.09% 0.98[0.47,2.03]
Su 2016 1/350 4/350 8.22% 0.25[0.03,2.23]
Venn 2001 2/10 1/10 2.06% 2[0.21,18.69]
Subtotal (95% CI) 965 950 39.37% 0.88[0.46,1.67]
Total (95% CI) 1917 1796 100% 0.63[0.4,0.98]

Test for subgroup differences: Chi2=1.92, df=1 (P=0.17), I2=47.94%
Informed decisions.

surgery - stratified by vascular versus non-vascular surgery, Outcome 2 Cardiac mortality.
ergic agonists
McSPI-Europe 1997 1/197 1/103 4.4% 0.52[0.03,8.27]
Oliver 1999 6/454 18/450 60.55% 0.33[0.13,0.82]
Quintin 1996 0/10 1/11 4.81% 0.36[0.02,8.03]
Stuhmeier 1996 1/145 2/152 6.54% 0.52[0.05,5.72]
Subtotal (95% CI) 806 716 76.3% 0.36[0.16,0.79]

Oliver 1999 7/502 7/491 23.7% 0.98[0.35,2.77]
Subtotal (95% CI) 502 491 23.7% 0.98[0.35,2.77]
Total (95% CI) 1308 1207 100% 0.51[0.27,0.93]


surgery - stratified by vascular versus non-vascular surgery, Outcome 3 Myocardial infarction.
ergic agonists
Ellis 1994 0/30 2/31 2.56% 0.21[0.01,4.13]
McSPI-Europe 1997 3/197 6/103 10.12% 0.26[0.07,1.02]
Oliver 1999 42/454 53/450 35.32% 0.79[0.54,1.15]
Soliman 2016 1/75 3/75 4.38% 0.33[0.04,3.13]
Stuhmeier 1996 0/145 4/152 2.7% 0.12[0.01,2.14]
Subtotal (95% CI) 934 832 55.07% 0.52[0.27,1]

Oliver 1999 36/502 26/491 31.16% 1.35[0.83,2.21]
Informed decisions.
ergic agonists
Su 2016 5/350 8/350 13.76% 0.63[0.21,1.89]
Subtotal (95% CI) 892 881 44.93% 1.09[0.55,2.15]
Total (95% CI) 1826 1713 100% 0.71[0.44,1.17]

Analysis 3.4. Comparison 3 Alpha-2 adrenergic agonists versus control in non-cardiac surgery
- stratified by vascular versus non-vascular surgery, Outcome 4 Myocardial ischaemia.
ergic agonists
Ellis 1994 7/28 8/26 13.27% 0.81[0.34,1.92]
Lipszyc 1991 8/20 5/20 12.07% 1.6[0.63,4.05]
McSPI-Europe 1997 35/197 16/103 21.12% 1.14[0.67,1.97]
Soliman 2016 3/75 14/75 8.38% 0.21[0.06,0.72]
Stuhmeier 1996 35/145 59/152 27.17% 0.62[0.44,0.88]
Talke 1995 11/18 3/6 12.93% 1.22[0.51,2.95]
Subtotal (95% CI) 483 382 94.94% 0.83[0.54,1.29]

Ghignone 1987 0/15 2/15 1.75% 0.2[0.01,3.85]
Matot 2000 0/18 2/18 1.73% 0.2[0.01,3.89]
Pawlik 2005 0/15 1/15 1.57% 0.33[0.01,7.58]
Subtotal (95% CI) 48 48 5.06% 0.23[0.04,1.34]
Total (95% CI) 531 430 100% 0.78[0.52,1.17]

Informed decisions.
Comparison 4. Alpha-2 adrenergic agonists (stratified by drug) versus control in non-cardiac surgery
Outcome or sub- No. of studies No. of partici- Statistical method Effect size
group title pants
1.1 Clonidine 7 10787 Risk Ratio (M-H, Fixed, 95% CI) 0.89 [0.64, 1.23]
1.2 Dexmedetomidine 7 1097 Risk Ratio (M-H, Fixed, 95% CI) 0.49 [0.15, 1.58]
1.3 Mivazerol 2 2197 Risk Ratio (M-H, Fixed, 95% CI) 0.69 [0.42, 1.15]
2.1 Clonidine 3 10328 Risk Ratio (M-H, Fixed, 95% CI) 1.12 [0.71, 1.75]
2.2 Mivazerol 2 2197 Risk Ratio (M-H, Fixed, 95% CI) 0.51 [0.27, 0.98]
3 Myocardial infarc- 12 13907 Risk Ratio (M-H, Random, 95% CI) 0.94 [0.69, 1.27]
tion
3.1 Clonidine 6 10756 Risk Ratio (M-H, Random, 95% CI) 1.05 [0.57, 1.92]
3.2 Dexmedetomidine 4 954 Risk Ratio (M-H, Random, 95% CI) 0.55 [0.20, 1.49]
3.3 Mivazerol 2 2197 Risk Ratio (M-H, Random, 95% CI) 0.60 [0.17, 2.08]
4.1 Clonidine 7 10485 Risk Ratio (M-H, Random, 95% CI) 1.29 [1.23, 1.35]
4.2 Dexmedetomidine 6 1056 Risk Ratio (M-H, Random, 95% CI) 1.81 [1.07, 3.06]
4.3 Mivazerol 2 2197 Risk Ratio (M-H, Random, 95% CI) 0.95 [0.82, 1.10]
Analysis 4.1. Comparison 4 Alpha-2 adrenergic agonists (stratified by

drug) versus control in non-cardiac surgery, Outcome 1 All-cause mortality.
ergic agonists
4.1.1 Clonidine
Devereaux 2014a 64/5009 63/5001 52.79% 1.01[0.72,1.43]
Ellis 1994 0/30 1/31 1.24% 0.34[0.01,8.13]
Quintin 1996 0/11 1/10 1.31% 0.31[0.01,6.74]
Stuhmeier 1996 1/145 2/152 1.64% 0.52[0.05,5.72]
Wallace 2004 1/125 4/65 4.41% 0.13[0.01,1.14]
Wijeysundera 2014a 0/82 2/86 2.04% 0.21[0.01,4.3]
Subtotal (95% CI) 5422 5365 63.42% 0.89[0.64,1.23]
Informed decisions.
ergic agonists
4.1.2 Dexmedetomidine
Soliman 2016 0/75 1/75 1.26% 0.33[0.01,8.05]
Su 2016 1/350 4/350 3.35% 0.25[0.03,2.23]
Talke 2000 0/22 1/19 1.34% 0.29[0.01,6.72]
Venn 2001 2/10 1/10 0.84% 2[0.21,18.69]
Subtotal (95% CI) 558 539 6.79% 0.49[0.15,1.58]
4.1.3 Mivazerol
McSPI-Europe 1997 4/197 1/103 1.1% 2.09[0.24,18.47]
Oliver 1999 22/956 34/941 28.69% 0.64[0.38,1.08]
Subtotal (95% CI) 1153 1044 29.79% 0.69[0.42,1.15]
Total (95% CI) 7133 6948 100% 0.8[0.61,1.04]

Test for subgroup differences: Chi2=1.38, df=1 (P=0.5), I2=0%

drug) versus control in non-cardiac surgery, Outcome 2 Cardiac mortality.
ergic agonists
4.2.1 Clonidine
Devereaux 2014a 38/5009 32/5001 51.72% 1.19[0.74,1.89]
Quintin 1996 0/10 1/11 2.32% 0.36[0.02,8.03]
Stuhmeier 1996 1/145 2/152 3.15% 0.52[0.05,5.72]
Subtotal (95% CI) 5164 5164 57.19% 1.12[0.71,1.75]
4.2.2 Mivazerol
McSPI-Europe 1997 1/197 1/103 2.12% 0.52[0.03,8.27]
Oliver 1999 13/956 25/941 40.69% 0.51[0.26,0.99]
Subtotal (95% CI) 1153 1044 42.81% 0.51[0.27,0.98]
Informed decisions.
ergic agonists
Heterogeneity: Tau2=0; Chi2=0, df=1(P=0.99); I2=0%
Total (95% CI) 6317 6208 100% 0.86[0.6,1.23]

Analysis 4.3. Comparison 4 Alpha-2 adrenergic agonists (stratified by drug)

versus control in non-cardiac surgery, Outcome 3 Myocardial infarction.
ergic agonists
4.3.1 Clonidine
Devereaux 2014a 329/5009 295/5001 41.71% 1.11[0.96,1.3]
Ellis 1994 0/30 2/31 1.02% 0.21[0.01,4.13]
Stuhmeier 1996 0/145 4/152 1.08% 0.12[0.01,2.14]
Wallace 2004 2/125 2/65 2.37% 0.52[0.07,3.61]
Wijeysundera 2014a 12/82 6/86 8.75% 2.1[0.83,5.33]
Subtotal (95% CI) 5406 5350 54.94% 1.05[0.57,1.92]
Soliman 2016 1/75 3/75 1.79% 0.33[0.04,3.13]
Su 2016 5/350 8/350 6.56% 0.63[0.21,1.89]
Subtotal (95% CI) 483 471 8.36% 0.55[0.2,1.49]
4.3.3 Mivazerol
McSPI-Europe 1997 3/197 6/103 4.54% 0.26[0.07,1.02]
Oliver 1999 78/956 79/941 32.17% 0.97[0.72,1.31]
Subtotal (95% CI) 1153 1044 36.71% 0.6[0.17,2.08]
Total (95% CI) 7042 6865 100% 0.94[0.69,1.27]

Informed decisions.
ergic agonists

drug) versus control in non-cardiac surgery, Outcome 4 Hypotension.
ergic agonists
4.4.1 Clonidine
Devereaux 2014a 2385/5009 1854/5001 24.64% 1.28[1.23,1.35]
Ghignone 1987 1/15 3/15 0.69% 0.33[0.04,2.85]
Matot 2000 2/18 0/18 0.36% 5[0.26,97.37]
Pluskwa 1991 12/15 8/15 7.79% 1.5[0.88,2.57]
Quintin 1996 5/11 2/10 1.56% 2.27[0.56,9.2]
Wallace 2004 24/125 11/65 5.93% 1.13[0.59,2.17]
Wijeysundera 2014a 7/82 6/86 2.65% 1.22[0.43,3.49]
Subtotal (95% CI) 5275 5210 43.63% 1.29[1.23,1.35]
Test for overall effect: Z=10.7(P<0.0001)
Bergese 2010 15/55 3/50 2.14% 4.55[1.4,14.78]
Lee 2013a 10/28 3/29 2.14% 3.45[1.06,11.25]
Soliman 2016 7/75 3/75 1.76% 2.33[0.63,8.68]
Su 2016 34/350 32/350 9.55% 1.06[0.67,1.68]
Talke 1995 17/18 4/6 7.04% 1.42[0.8,2.52]
Subtotal (95% CI) 536 520 22.63% 1.81[1.07,3.06]
4.4.3 Mivazerol
McSPI-Europe 1997 127/197 72/103 20.77% 0.92[0.78,1.09]
Oliver 1999 62/956 57/941 12.97% 1.07[0.76,1.52]
Subtotal (95% CI) 1153 1044 33.73% 0.95[0.82,1.1]
Total (95% CI) 6964 6774 100% 1.24[1.03,1.48]

Test for subgroup differences: Chi2=16.72, df=1 (P=0), I2=88.04%
Informed decisions.
Comparison 5. Alpha-2 adrenergic agonists versus control in non-cardiac surgery studies with blinding and
concealed allocation
Outcome or subgroup title No. of studies No. of partici- Statistical method Effect size
pants
1 All-cause mortality 7 13066 Risk Ratio (M-H, Random, 95% CI) 0.68 [0.41, 1.11]

surgery studies with blinding and concealed allocation, Outcome 1 All-cause mortality.
ergic agonists
Devereaux 2014a 64/5009 63/5001 48.51% 1.01[0.72,1.43]
Ellis 1994 0/30 1/31 2.38% 0.34[0.01,8.13]
Oliver 1999 22/956 34/941 36.91% 0.64[0.38,1.08]
Su 2016 1/350 4/350 4.78% 0.25[0.03,2.23]
Wallace 2004 1/125 4/65 4.84% 0.13[0.01,1.14]
Wijeysundera 2014a 0/82 2/86 2.59% 0.21[0.01,4.3]
Total (95% CI) 6572 6494 100% 0.68[0.41,1.11]


surgery studies with blinding and concealed allocation, Outcome 2 Myocardial infarction.
ergic agonists
Devereaux 2014a 329/5009 295/5001 74.97% 1.11[0.96,1.3]
Ellis 1994 0/30 2/31 0.62% 0.21[0.01,4.13]
Oliver 1999 78/956 79/941 20.22% 0.97[0.72,1.31]
Su 2016 5/350 8/350 2.03% 0.63[0.21,1.89]
Wallace 2004 2/125 2/65 0.67% 0.52[0.07,3.61]
Wijeysundera 2014a 12/82 6/86 1.49% 2.1[0.83,5.33]
Total (95% CI) 6552 6474 100% 1.08[0.95,1.23]

Informed decisions.
ergic agonists

surgery studies with blinding and concealed allocation, Outcome 3 Myocardial ischaemia.
ergic agonists
Ellis 1994 7/28 8/26 27.79% 0.81[0.34,1.92]
Wallace 2004 18/125 20/65 38.7% 0.47[0.27,0.82]
Wijeysundera 2014a 15/82 12/86 33.51% 1.31[0.65,2.63]
Total (95% CI) 235 177 100% 0.77[0.4,1.48]

Comparison 6. Alpha-2 adrenergic agonists versus control in studies that used strict definitions of myocardial
infarction or ischaemia
tle pants
1 Myocardial infarction 11 Risk Ratio (M-H, Random, 95% CI) Subtotals only
1.1 Non-cardiac surgery 8 13003 Risk Ratio (M-H, Random, 95% CI) 0.98 [0.70, 1.36]
1.2 Cardiac surgery 3 275 Risk Ratio (M-H, Random, 95% CI) 0.76 [0.19, 2.98]
2 Myocardial ischaemia 17 Risk Ratio (M-H, Random, 95% CI) Subtotals only
2.1 Non-cardiac surgery 9 1175 Risk Ratio (M-H, Random, 95% CI) 0.76 [0.54, 1.07]
2.2 Cardiac surgery 8 820 Risk Ratio (M-H, Random, 95% CI) 0.71 [0.55, 0.91]
Analysis 6.1. Comparison 6 Alpha-2 adrenergic agonists versus control in studies that used
strict definitions of myocardial infarction or ischaemia, Outcome 1 Myocardial infarction.
ergic agonists
6.1.1 Non-cardiac surgery
Devereaux 2014a 329/5009 295/5001 44.62% 1.11[0.96,1.3]
Informed decisions.
ergic agonists
Ellis 1994 0/30 2/31 1.18% 0.21[0.01,4.13]
McSPI-Europe 1997 3/197 6/103 5.21% 0.26[0.07,1.02]
Oliver 1999 78/956 79/941 35.03% 0.97[0.72,1.31]
Stuhmeier 1996 0/145 4/152 1.25% 0.12[0.01,2.14]
Wallace 2004 2/125 2/65 2.74% 0.52[0.07,3.61]
Wijeysundera 2014a 12/82 6/86 9.97% 2.1[0.83,5.33]
Subtotal (95% CI) 6584 6419 100% 0.98[0.7,1.36]
6.1.2 Cardiac surgery

Jalonen 1997 2/40 3/40 62.49% 0.67[0.12,3.78]
Loick 1999 1/24 0/21 18.97% 2.64[0.11,61.54]
Myles 1999 0/76 1/74 18.54% 0.32[0.01,7.84]
Subtotal (95% CI) 140 135 100% 0.76[0.19,2.98]
Analysis 6.2. Comparison 6 Alpha-2 adrenergic agonists versus control in studies that used
strict definitions of myocardial infarction or ischaemia, Outcome 2 Myocardial ischaemia.
ergic agonists
6.2.1 Non-cardiac surgery
Ellis 1994 7/28 8/26 10.16% 0.81[0.34,1.92]
Ghignone 1987 0/15 2/15 1.26% 0.2[0.01,3.85]
Lipszyc 1991 8/20 5/20 9.18% 1.6[0.63,4.05]
Matot 2000 0/18 2/18 1.25% 0.2[0.01,3.89]
McSPI-Europe 1997 35/197 16/103 16.85% 1.14[0.67,1.97]
Stuhmeier 1996 35/145 59/152 22.41% 0.62[0.44,0.88]
Wallace 2004 18/125 20/65 16.31% 0.47[0.27,0.82]
Wijeysundera 2014a 15/82 12/86 13.16% 1.31[0.65,2.63]
Yin 2002 5/30 12/30 9.42% 0.42[0.17,1.04]
Subtotal (95% CI) 660 515 100% 0.76[0.54,1.07]
6.2.2 Cardiac surgery

Abi-Jaoude 1993 2/11 3/13 2.48% 0.79[0.16,3.9]
El-Kerdawy 2004 0/25 7/25 0.81% 0.07[0,1.11]
Jalonen 1997 14/40 19/40 20.49% 0.74[0.43,1.26]
Loick 1999 6/14 11/15 13.15% 0.58[0.3,1.15]
Informed decisions.
ergic agonists
Myles 1999 15/76 22/74 17.97% 0.66[0.37,1.18]
Quintin 1993 3/13 6/13 4.71% 0.5[0.16,1.58]
Ren 2013 6/81 15/81 7.71% 0.4[0.16,0.98]
Shehabi 2009 35/152 35/147 32.68% 0.97[0.64,1.46]
Subtotal (95% CI) 412 408 100% 0.71[0.55,0.91]
Comparison 7. Alpha-2 adrenergic agonists versus control in non-cardiac surgery (excluding Oliver 1999 and
Devereaux 2014)
Outcome or subgroup title No. of studies No. of partici- Statistical method Effect size
pants

surgery (excluding Oliver 1999 and Devereaux 2014), Outcome 1 All-cause mortality.
ergic agonists
Ellis 1994 0/30 1/31 6.67% 0.34[0.01,8.13]
McSPI-Europe 1997 4/197 1/103 5.94% 2.09[0.24,18.47]
Quintin 1996 0/11 1/10 7.08% 0.31[0.01,6.74]
Soliman 2016 0/75 1/75 6.78% 0.33[0.01,8.05]
Stuhmeier 1996 1/145 2/152 8.83% 0.52[0.05,5.72]
Su 2016 1/350 4/350 18.09% 0.25[0.03,2.23]
Talke 2000 0/22 1/19 7.26% 0.29[0.01,6.72]
Venn 2001 2/10 1/10 4.52% 2[0.21,18.69]
Wallace 2004 1/125 4/65 23.8% 0.13[0.01,1.14]
Wijeysundera 2014a 0/82 2/86 11.04% 0.21[0.01,4.3]
Total (95% CI) 1168 1006 100% 0.45[0.22,0.93]

Informed decisions.
ergic agonists

surgery (excluding Oliver 1999 and Devereaux 2014), Outcome 2 Cardiac mortality.
ergic agonists
McSPI-Europe 1997 1/197 1/103 27.94% 0.52[0.03,8.27]
Quintin 1996 0/10 1/11 30.52% 0.36[0.02,8.03]
Stuhmeier 1996 1/145 2/152 41.54% 0.52[0.05,5.72]
Total (95% CI) 352 266 100% 0.47[0.1,2.25]


surgery (excluding Oliver 1999 and Devereaux 2014), Outcome 3 Myocardial infarction.
ergic agonists
Ellis 1994 0/30 2/31 6.04% 0.21[0.01,4.13]
McSPI-Europe 1997 3/197 6/103 18.28% 0.26[0.07,1.02]
Soliman 2016 1/75 3/75 9.63% 0.33[0.04,3.13]
Stuhmeier 1996 0/145 4/152 6.34% 0.12[0.01,2.14]
Su 2016 5/350 8/350 22.33% 0.63[0.21,1.89]
Wallace 2004 2/125 2/65 11.89% 0.52[0.07,3.61]
Wijeysundera 2014a 12/82 6/86 25.5% 2.1[0.83,5.33]
Total (95% CI) 1077 923 100% 0.56[0.25,1.25]

Informed decisions.
Comparison 8. Alpha-2 adrenergic agonists (excluding mivazerol) versus control in non-cardiac surgery
title pants
yarrhythmia
8 Bradycardia 14 11838 Risk Ratio (M-H, Random, 95% CI) 1.66 [1.17, 2.36]
Analysis 8.1. Comparison 8 Alpha-2 adrenergic agonists (excluding mivazerol)

versus control in non-cardiac surgery, Outcome 1 All-cause mortality.
ergic agonists
Devereaux 2014a 64/5009 63/5001 75.19% 1.01[0.72,1.43]
Ellis 1994 0/30 1/31 1.76% 0.34[0.01,8.13]
Quintin 1996 0/11 1/10 1.87% 0.31[0.01,6.74]
Soliman 2016 0/75 1/75 1.79% 0.33[0.01,8.05]
Stuhmeier 1996 1/145 2/152 2.33% 0.52[0.05,5.72]
Su 2016 1/350 4/350 4.77% 0.25[0.03,2.23]
Talke 2000 0/22 1/19 1.91% 0.29[0.01,6.72]
Venn 2001 2/10 1/10 1.19% 2[0.21,18.69]
Wallace 2004 1/125 4/65 6.28% 0.13[0.01,1.14]
Wijeysundera 2014a 0/82 2/86 2.91% 0.21[0.01,4.3]
Total (95% CI) 5980 5904 100% 0.85[0.62,1.16]

Informed decisions.

versus control in non-cardiac surgery, Outcome 2 Cardiac mortality.
ergic agonists
Devereaux 2014a 38/5009 32/5001 90.43% 1.19[0.74,1.89]
Quintin 1996 0/10 1/11 4.05% 0.36[0.02,8.03]
Stuhmeier 1996 1/145 2/152 5.51% 0.52[0.05,5.72]
Total (95% CI) 5164 5164 100% 1.12[0.71,1.75]


versus control in non-cardiac surgery, Outcome 3 Myocardial infarction.
ergic agonists
Devereaux 2014a 329/5009 295/5001 53.71% 1.11[0.96,1.3]
Ellis 1994 0/30 2/31 2.41% 0.21[0.01,4.13]
Soliman 2016 1/75 3/75 4.17% 0.33[0.04,3.13]
Stuhmeier 1996 0/145 4/152 2.54% 0.12[0.01,2.14]
Su 2016 5/350 8/350 13.9% 0.63[0.21,1.89]
Wallace 2004 2/125 2/65 5.44% 0.52[0.07,3.61]
Wijeysundera 2014a 12/82 6/86 17.83% 2.1[0.83,5.33]
Total (95% CI) 5889 5821 100% 0.95[0.59,1.53]


versus control in non-cardiac surgery, Outcome 4 Myocardial ischaemia.
ergic agonists
Ellis 1994 7/28 8/26 10.28% 0.81[0.34,1.92]
Ghignone 1987 0/15 2/15 1.34% 0.2[0.01,3.85]
Lipszyc 1991 8/20 5/20 9.35% 1.6[0.63,4.05]
Matot 2000 0/18 2/18 1.33% 0.2[0.01,3.89]
Pawlik 2005 0/15 1/15 1.21% 0.33[0.01,7.58]
Informed decisions.
ergic agonists
Soliman 2016 3/75 14/75 6.46% 0.21[0.06,0.72]
Stuhmeier 1996 35/145 59/152 21.32% 0.62[0.44,0.88]
Talke 1995 11/18 3/6 10.02% 1.22[0.51,2.95]
Wallace 2004 18/125 20/65 16% 0.47[0.27,0.82]
Wijeysundera 2014a 15/82 12/86 13.12% 1.31[0.65,2.63]
Yin 2002 5/30 12/30 9.58% 0.42[0.17,1.04]
Total (95% CI) 571 508 100% 0.68[0.48,0.97]


versus control in non-cardiac surgery, Outcome 5 Supraventricular tachyarrhythmia.
ergic agonists
Talke 1995 1/18 0/6 100% 1.11[0.05,24.07]
Total (95% CI) 28 16 100% 1.11[0.05,24.07]

Analysis 8.6. Comparison 8 Alpha-2 adrenergic agonists (excluding

mivazerol) versus control in non-cardiac surgery, Outcome 6 Heart failure.
ergic agonists
Devereaux 2014a 48/5009 34/5001 75.67% 1.41[0.91,2.18]
Ellis 1994 4/28 5/26 11.53% 0.74[0.22,2.47]
Talke 1995 2/18 1/6 3.34% 0.67[0.07,6.11]
Wallace 2004 0/125 2/65 7.3% 0.1[0.01,2.15]
Wijeysundera 2014a 3/82 1/86 2.17% 3.15[0.33,29.64]
Total (95% CI) 5290 5212 100% 1.25[0.85,1.84]

Informed decisions.

mivazerol) versus control in non-cardiac surgery, Outcome 7 Acute stroke.
ergic agonists
Devereaux 2014a 18/5009 17/5001 75.61% 1.06[0.55,2.05]
Su 2016 0/350 3/350 15.55% 0.14[0.01,2.76]
Talke 1995 1/16 1/8 5.93% 0.5[0.04,7]
Wallace 2004 1/125 0/65 2.92% 1.57[0.06,38.04]
Total (95% CI) 5657 5585 100% 0.9[0.49,1.63]


mivazerol) versus control in non-cardiac surgery, Outcome 8 Bradycardia.
ergic agonists
Bergese 2010 4/55 0/50 1.41% 8.2[0.45,148.52]
Devereaux 2014a 600/5009 403/5001 37.99% 1.49[1.32,1.68]
Lee 2013a 11/28 4/29 9.08% 2.85[1.03,7.9]
Pawlik 2005 2/15 0/15 1.35% 5[0.26,96.13]
Pluskwa 1991 7/15 4/15 9.37% 1.75[0.64,4.75]
Quintin 1996 2/11 2/10 3.58% 0.91[0.16,5.3]
Soliman 2016 9/75 2/75 4.79% 4.5[1.01,20.13]
Stuhmeier 1996 23/145 30/152 22.2% 0.8[0.49,1.32]
Su 2016 5/350 1/350 2.5% 5[0.59,42.58]
Talke 1995 8/18 0/6 1.59% 6.26[0.41,94.82]
Wallace 2004 12/125 2/65 4.97% 3.12[0.72,13.52]
Wijeysundera 2014a 1/82 0/86 1.17% 3.14[0.13,76.11]
Total (95% CI) 5956 5882 100% 1.66[1.17,2.36]

Informed decisions.

mivazerol) versus control in non-cardiac surgery, Outcome 9 Hypotension.
ergic agonists
Bergese 2010 15/55 3/50 1.55% 4.55[1.4,14.78]
Devereaux 2014a 2385/5009 1854/5001 64.96% 1.28[1.23,1.35]
Ghignone 1987 1/15 3/15 0.48% 0.33[0.04,2.85]
Lee 2013a 10/28 3/29 1.55% 3.45[1.06,11.25]
Matot 2000 2/18 0/18 0.25% 5[0.26,97.37]
Pluskwa 1991 12/15 8/15 6.89% 1.5[0.88,2.57]
Quintin 1996 5/11 2/10 1.11% 2.27[0.56,9.2]
Soliman 2016 7/75 3/75 1.25% 2.33[0.63,8.68]
Su 2016 34/350 32/350 9.08% 1.06[0.67,1.68]
Talke 1995 17/18 4/6 6.05% 1.42[0.8,2.52]
Wallace 2004 24/125 11/65 4.89% 1.13[0.59,2.17]
Wijeysundera 2014a 7/82 6/86 1.95% 1.22[0.43,3.49]
Total (95% CI) 5811 5730 100% 1.33[1.15,1.55]

Comparison 9. Alpha-2 adrenergic agonists versus control in non-cardiac surgery within past 20 years
title pants
Analysis 9.1. Comparison 9 Alpha-2 adrenergic agonists versus control in

non-cardiac surgery within past 20 years, Outcome 1 All-cause mortality.
ergic agonists
Informed decisions.
ergic agonists
Devereaux 2014a 64/5009 63/5001 55.73% 1.01[0.72,1.43]
Oliver 1999 22/956 34/941 30.29% 0.64[0.38,1.08]
Soliman 2016 0/75 1/75 1.33% 0.33[0.01,8.05]
Su 2016 1/350 4/350 3.54% 0.25[0.03,2.23]
Talke 2000 0/22 1/19 1.42% 0.29[0.01,6.72]
Venn 2001 2/10 1/10 0.88% 2[0.21,18.69]
Wallace 2004 1/125 4/65 4.65% 0.13[0.01,1.14]
Wijeysundera 2014a 0/82 2/86 2.16% 0.21[0.01,4.3]
Total (95% CI) 6732 6646 100% 0.8[0.61,1.06]


non-cardiac surgery within past 20 years, Outcome 2 Cardiac mortality.
ergic agonists
Devereaux 2014a 38/5009 32/5001 55.97% 1.19[0.74,1.89]
Oliver 1999 13/956 25/941 44.03% 0.51[0.26,0.99]
Total (95% CI) 5965 5942 100% 0.89[0.61,1.29]


non-cardiac surgery within past 20 years, Outcome 3 Myocardial infarction.
ergic agonists
Devereaux 2014a 329/5009 295/5001 72.94% 1.11[0.96,1.3]
Oliver 1999 78/956 79/941 21.98% 0.97[0.72,1.31]
Soliman 2016 1/75 3/75 0.42% 0.33[0.04,3.13]
Su 2016 5/350 8/350 1.7% 0.63[0.21,1.89]
Wallace 2004 2/125 2/65 0.56% 0.52[0.07,3.61]
Wijeysundera 2014a 12/82 6/86 2.4% 2.1[0.83,5.33]
Informed decisions.
ergic agonists
Total (95% CI) 6637 6558 100% 1.08[0.93,1.24]
Test for overall effect: Z=1(P=0.32)

non-cardiac surgery within past 20 years, Outcome 4 Myocardial ischaemia.
ergic agonists
Matot 2000 0/18 2/18 3.74% 0.2[0.01,3.89]
Pawlik 2005 0/15 1/15 3.41% 0.33[0.01,7.58]
Soliman 2016 3/75 14/75 15.47% 0.21[0.06,0.72]
Wallace 2004 18/125 20/65 30.02% 0.47[0.27,0.82]
Wijeysundera 2014a 15/82 12/86 26.34% 1.31[0.65,2.63]
Yin 2002 5/30 12/30 21.03% 0.42[0.17,1.04]
Total (95% CI) 345 289 100% 0.51[0.28,0.93]


in non-cardiac surgery within past 20 years, Outcome 5 Heart failure.
ergic agonists
Devereaux 2014a 48/5009 34/5001 88.88% 1.41[0.91,2.18]
Wallace 2004 0/125 2/65 8.57% 0.1[0.01,2.15]
Wijeysundera 2014a 3/82 1/86 2.55% 3.15[0.33,29.64]
Total (95% CI) 5244 5180 100% 1.34[0.89,2.03]

Informed decisions.

in non-cardiac surgery within past 20 years, Outcome 6 Acute stroke.
ergic agonists
Devereaux 2014a 18/5009 17/5001 80.37% 1.06[0.55,2.05]
Su 2016 0/350 3/350 16.53% 0.14[0.01,2.76]
Wallace 2004 1/125 0/65 3.1% 1.57[0.06,38.04]
Total (95% CI) 5641 5577 100% 0.92[0.5,1.7]

Comparison 10. Alpha-2 adrenergic agonists versus control in cardiac surgery within past 20 years
tle pants
3 Myocardial ischaemia 7 908 Risk Ratio (M-H, Fixed, 95% CI) 0.72 [0.54, 0.96]
yarrhythmia

in cardiac surgery within past 20 years, Outcome 1 All-cause mortality.
ergic agonists
Cho 2016 1/100 5/100 22.24% 0.2[0.02,1.68]
Corbett 2005 1/43 0/46 2.15% 3.2[0.13,76.6]
Djaiani 2016 1/91 0/92 2.21% 3.03[0.13,73.48]
Khalil 2013 0/25 0/25 Not estimable
Kim 2014a 0/40 1/38 6.84% 0.32[0.01,7.55]
Li 2017 2/142 4/143 17.73% 0.5[0.09,2.71]
Liu 2016 0/44 1/44 6.67% 0.33[0.01,7.97]
Informed decisions.
ergic agonists
Myles 1999 0/76 2/74 11.27% 0.19[0.01,3.99]
Ren 2013 0/81 0/81 Not estimable
Shehabi 2009 2/152 4/147 18.09% 0.48[0.09,2.6]
Venn 1999 1/47 3/51 12.8% 0.36[0.04,3.36]
Total (95% CI) 891 891 100% 0.47[0.23,0.97]


in cardiac surgery within past 20 years, Outcome 2 Myocardial infarction.
ergic agonists
Herr 2003 3/148 1/147 20.38% 2.98[0.31,28.32]
Myles 1999 0/76 1/74 30.87% 0.32[0.01,7.84]
Venn 1999 0/47 2/51 48.75% 0.22[0.01,4.4]
Total (95% CI) 296 297 100% 0.81[0.22,3.03]


in cardiac surgery within past 20 years, Outcome 3 Myocardial ischaemia.
ergic agonists
Ammar 2016 1/25 1/25 1.08% 1[0.07,15.12]
El-Kerdawy 2004 0/25 7/25 8.12% 0.07[0,1.11]
Kim 2014a 1/40 1/38 1.11% 0.95[0.06,14.65]
Myles 1999 15/76 22/74 24.13% 0.66[0.37,1.18]
Ren 2013 6/81 15/81 16.24% 0.4[0.16,0.98]
Shehabi 2009 35/152 35/147 38.52% 0.97[0.64,1.46]
Venn 1999 10/66 9/53 10.81% 0.89[0.39,2.04]
Total (95% CI) 465 443 100% 0.72[0.54,0.96]

Informed decisions.
ergic agonists
Analysis 10.4. Comparison 10 Alpha-2 adrenergic agonists versus control in cardiac

surgery within past 20 years, Outcome 4 Supraventricular tachyarrhythmia.
ergic agonists
Corbett 2005 1/43 0/46 1.38% 3.2[0.13,76.6]
Herr 2003 12/148 12/147 34.25% 0.99[0.46,2.14]
Ren 2013 2/81 12/81 34.14% 0.17[0.04,0.72]
Shehabi 2009 3/152 5/147 14.46% 0.58[0.14,2.38]
Venn 1999 8/66 5/53 15.78% 1.28[0.45,3.7]
Total (95% CI) 490 474 100% 0.73[0.44,1.19]


control in cardiac surgery within past 20 years, Outcome 5 Heart failure.
ergic agonists
Herr 2003 3/148 4/147 24.82% 0.74[0.17,3.27]
Myles 1999 12/76 12/74 75.18% 0.97[0.47,2.03]
Total (95% CI) 224 221 100% 0.92[0.48,1.77]


control in cardiac surgery within past 20 years, Outcome 6 Acute stroke.
ergic agonists
Cho 2016 0/100 4/100 30.52% 0.11[0.01,2.04]
Informed decisions.
ergic agonists
Li 2017 3/142 3/143 20.28% 1.01[0.21,4.91]
Park 2014 0/67 2/75 16.01% 0.22[0.01,4.57]
Shehabi 2009 1/152 1/147 6.9% 0.97[0.06,15.32]
Venn 1999 0/66 3/53 26.29% 0.12[0.01,2.18]
Total (95% CI) 552 543 100% 0.37[0.14,0.98]

APPENDICES
Appendix 1. Search terms for electronic databases
MEDLINE (OvidSP) search terms:
1. postoperative complications/ or perioperative care/ or intraoperative complications/ or (intraoperative or perioperative or post-

operative).mp.
2. exp clonidine/ or exp dexmedetomidine/ or mivazerol.mp.
3. ((randomized controlled trial or controlled clinical trial).pt. or randomized.ab. or placebo.ab. or drug therapy.fs. or randomly.ab. or
trial.ab. or groups.ab.) not (animals not (humans and animals)).sh.
4. 1 and 2 and 3
Embase (OvidSP) search terms
1. postoperative complication/ or postoperative period/ or perioperative period/ or intraoperative period/ or peroperative care/ or
peroperative complication/ or (perioperative or intraoperative or postoperative).ti,ab.
2. clonidine/ or dexmedetomidine/ or mivazerol.ti,ab.
3. (randomized-controlled-trial/ or randomization/ or controlled-study/ or multicenter-study/ or phase-3-clinical-trial/ or phase-4-

clinical-trial/ or double-blind-procedure/ or single-blind-procedure/ or (random* or cross?over* or multicenter* or factorial* or place-
bo* or volunteer*).mp. or ((singl* or doubl* or trebl* or tripl*) adj3 (blind* or mask*)).ti,ab. or (latin adj square).mp.) not (animals not
(humans and animals)).sh.
4. 1 and 2 and 3
CENTRAL search terms
#1 clonidine OR dexmedetomidine OR mivazerol

#2 perioperative OR preoperative OR postoperative
#3 #1 AND #2
Appendix 2. Data abstraction form

Study ID:
Informed decisions.
Reviewer:
Title:
Authors:
Journal:
Year: Volume:
Issue: Pages
Study quality
Randomized?
Allocation concealed?
How?
Blinded?
Intention-to-treat?
Drop-outs accounted?
Include?
Overall features
Surgical population (inclusion/exclusion):
Anesthesia type:
Alpha-2 agonist regimen(s) (dose, frequency)
Control arm regimens
Follow-up duration
Main outcome data
Dose & regimen:
Patients (n):
All-cause mortality:
Cardiac death:
Myocardial infarction:
Myocardial ischaemia:
Heart failure:
Supraventricular tachyarrhythmia:
Definition of myocardial infarction:
Definition of myocardial ischaemia:
Side effects data
Hypotension:
Bradycardia:
Acute stroke:
Informed decisions.
Other (specify):
Comments:
Subgroup results
Subgroup type:
Patients (n):
All-cause mortality:
Cardiac death:
Myocardial infarction:
Myocardial ischaemia:
Heart failure:
Supraventricular tachyarrhythmia:
Hypotension:
Bradycardia:
Acute stroke:
Other (specify):
Add further pages for any other relevant subgroups.
FEEDBACK
Why pool results, 1 April 2018

Summary
I am troubled by the summary statements, because analysing the three drugs together is problematic.
Why mix dexmedetomidine studies with clonidine studies and present their pooled results? They have vastly different specificities for the
alpha-2 receptor.
Why not include three subgroups, analysing studies of each of the drugs individually?
Meta-analysis of these drugs when used only in the postoperative setting would have been especially useful to Intensivists, especially
dexmedetomidine alone.
In this study, page 17, especially reading from “The influence of two large studies” on, seems to show BENEFITS of alpha -2 blockers when
two large studies (which did NOT include dexmedetomidine) were removed. Additional “subgroup” analyses after this section make for
interesting reading which is not really reflected in the summary statements.
The summary of papers does not include results - so a super-quick meta-analysis of the dexmedetomidine - only studies is made more
difficult.
In summary: this paper, Prima facie, debunks the use of these drugs perioperatively, but the details show that dexmedetomidine may well
be very useful.
Reply
The author has raised several important issues, especially methodological concerns pertaining to subgroup analyses.
The effects of clonidine, dexmedetomidine, and mivazerol may indeed plausibly differ based on their different selectivity for alpha-2
adrenoceptors and non-adrenergic imidazoline receptors. Consequently, we specifically conducted formal statistical testing for such
subgroup differences. This testing revealed no significant between-drug differences with respect to effects on death (P = 0.50) and
myocardial infarction (P = 0.48), and borderline differences with respect to effects on cardiac death (P = 0.05). Consequently, our primary
approach to present pooled treatment effects for all three drugs is consistent with existing published study data. Similarly, we advocate
Informed decisions.
against over interpreting the sensitivity analyses that excluded that two large studies, especially since there was only one resulting
statistically significant pooled treatment effect, which was itself based on 27 outcome events.
Conversely, we do agree that dexmedetomidine holds some promise as a beneficial perioperative intervention, especially when reviewing
more recent studies and studies restricted to cardiac surgery. Nonetheless, the findings of these subset analyses in our review may not be
robust, especially due to the risk of inflated Type 1 error (i.e., false positive findings) from repeated statistical testing. Thus, we chose against
including these potential benefits (e.g., significant reduction in mortality in contemporary cardiac surgery trials) in the summary statement
that represents the strength of current evidence. Instead, these potential benefits warrant rigorous assessment in future research involving
larger trials of specific drugs (i.e., dexmedetomidine) in targeted subgroups (i.e., cardiac surgery).
Contributors
Summary
David Collins. Intensivist / Anaesthetist. I do not have any affiliation with or involvement in any organisation with a financial interest in
the subject matter of my comment.
Reply
Duminda N. Wijeysundera, MD PhD FRCPC
Li Ka Shing Knowledge Institute, St. Michael’s Hospital
30 Bond Street, Toronto, Ontario
Canada
WHAT'S NEW
Date Event Description
12 September 2018 Feedback has been incorporated Reply to feedback summary incorporated (Feedback 1)
HISTORY
Protocol first published: Issue 2, 2003
Review first published: Issue 4, 2009
13 August 2018 Feedback has been incorporated Feedback summary incorporated (Feedback 1).
13 March 2018 Amended Typo corrected in Acknowledgements
4 May 2017 New citation required and conclusions No benefit of α-2 adrenergic agonists was identified with re-
have changed spect to the prevention of cardiac complications or death after
surgery. The study methods were updated to include summary
of findings tables, using GRADE methodology. The main analy-
ses were subdivided into cardiac and non-cardiac studies. The
inclusion criteria were broadened to include studies that only re-
ported on acute stroke and heart failure outcomes. All studies ex-
cluded in the prior review were re-evaluated using the new crite-
ria. The former author JS Bender has left the team and two new
authors have joined, namely D Duncan and A Sankar.
4 May 2017 New search has been performed 1721 abstracts were screened, 199 full-texts were assessed for el-
igibility and 19 additional studies were included. A search of clin-
ical trial registries identified one additional published study that
was included. Three previously included reports of two studies
Informed decisions.

(Boldt 1996; Wahlander 2005) are now excluded because of re-
ported scientific misconduct by lead authors. Two other previ-
ously included studies (Martin 2003; Triltsch 2002) are now ex-
cluded because the 2017 review conducted separate analyses
for cardiac and non-cardiac surgical procedures, and these two
studies could not be classified into either subgroup.
Sensitivity analyses were added to assess for the influence of (i)

studies that evaluated mivazerol and (ii) studies with data collec-
tion occurring more than 20 years previously.
1 August 2016 Amended This review has two included studies that have been retracted
(Boldt 1996; Wahlander 2005).
The Cochrane authors are in the process of updating this review.
22 May 2008 Amended Converted to new review format.
CONTRIBUTIONS OF AUTHORS
Conceiving the review: DNW, WSB.
Coordinating the review: DNW.
Undertaking manual searches: DD, AS.
Screening search results: DD, AS.
Organizing retrieval of papers: DD, AS.
Screening retrieved papers against inclusion criteria: DD, AS.
Appraising quality of papers: DD, AS.
Abstracting data from papers: DD, AS.
Writing to authors of papers for additional information: DD, AS.
Data management for the review: DD.
Entering data into Review Manager 5 (RevMan 2014): DD, AS.
RevMan statistical data: DD.
Interpretation of data: DD, AS, WSB, DNW.
Statistical inferences: DD, AS, WSB, DNW.
Writing the review: DD, AS, WSB, DNW.
Performing previous work that was the foundation of the present study: DNW, WSB.
Guarantor for the review (one author): DNW.
Person responsible for reading and checking review before submission: DNW.
DECLARATIONS OF INTEREST
DD: no conflict of interest.
AS: no conflicts of interest.
Informed decisions.
WSB: the senior author of one included study (Wijeysundera 2014a); however, he had no involvement in either the data abstraction or
quality assessment process. This author had no other relevant conflicts of interest.
DNW: the lead author of one included study (Wijeysundera 2014a); however, he had no involvement in either the primary data abstraction
or quality assessment process. This author had no other relevant conflicts of interest.
SOURCES OF SUPPORT
Internal sources
• Department of Anesthesia, University of Toronto, Canada.
External sources
• Canadian Institutes of Health Research, Canada.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

Several changes have been made since the publication of the original protocol (Wijeysundera 2003).
Changes for the 2018 review.
1. The target population of 'all major surgery' was divided into the subgroups of cardiac and non-cardiac surgical procedures for all
analyses. This alteration was in response to comments from an editorial board member, who raised concerns about the significant
clinical heterogeneity between cardiac versus non-cardiac surgical procedures.
2. We did not include a planned subgroup analysis comparing α-2 adrenergic agonists to control in people receiving epidural or spinal
anaesthesia as there was only one trial (Oliver 1999).
3. The inclusion criteria were broadened to include studies that only reported the outcomes of acute stroke and HF, based on comments
from an editorial board member.
4. Given the large influence of two large RCTs (Devereaux 2014a; Oliver 1999), we performed a post-hoc sensitivity analysis that excluded
these specific studies.
5. Based on based on comments received during the peer-review process, we performed post-hoc sensitivity analyses that excluded the
two RCTs of mivazerol (McSPI-Europe 1997; Oliver 1999) since it is not available for clinical use.
6. Based on comments received during the peer-review process, we performed post-hoc sensitivity analyses that excluded studies where
data collection or enrolment occurred more than 20 years ago, specifically to assess for the potential influence of temporal advances
in perioperative on pooled treatment effects.
7. The quality of evidence underlying the main estimated pooled treatment effects was assessed based on the GRADE methodology and
presented in 'Summary of findings' tables.
Changes for 2009 review (Wijeysundera 2009):
1. Based on comments from a peer reviewer (Peter Alston), the title was changed from 'Alpha-2 adrenergic agonists for the prevention
of cardiovascular complications among patients undergoing cardiac or non-cardiac surgery' to 'Alpha-2 adrenergic agonists for the
prevention of cardiac complications among patients undergoing surgery.'
2. We performed several post-hoc analyses that were not specified in the original protocol.
a. A subgroup analysis was performed based on drug type to explain the moderate heterogeneity for the pooled effect of α-2 adrenergic
agonists on perioperative hypotension.
b. We performed a post-hoc subgroup analysis based on surgical procedure to explain the significant heterogeneity for the pooled
effect of α-2 adrenergic agonists on perioperative bradycardia.
3. We have added acute stroke as a secondary outcome (side-effect from treatment) based on comments from a peer-reviewer (Helen
Higham), and the results of the POISE-1 trial (POISE 2008). Specifically, the POISE-1 trial found that perioperative beta-blockers caused
a significantly increased risk of perioperative acute stroke.
NOTES
August 2016
Two studies (Boldt 1996; Wahlander 2005), which were included in the previous 2009 version of this review (Wijeysundera 2009), were
removed from the 2016 version of the review due to concerns about scientific conduct.
Informed decisions.
INDEX TERMS
Medical Subject Headings (MeSH)

Adrenergic alpha-Agonists [adverse effects] [*therapeutic use]; Clonidine [therapeutic use]; Dexmedetomidine [therapeutic use];
Heart Diseases [mortality] [*prevention & control]; Imidazoles [therapeutic use]; Intraoperative Complications [mortality] [prevention
& control]; Myocardial Infarction [mortality] [prevention & control]; Postoperative Complications [mortality] [*prevention & control];
Randomized Controlled Trials as Topic; Stress, Physiological [drug effects]; Stroke [mortality]; Surgical Procedures, Operative
[*adverse effects] [mortality]
MeSH check words

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Cochrane

Alpha-2 adrenergic agonists for the prevention of cardiac

Duncan D, Sankar A, Beattie WS, Wijeysundera DN

Duncan D, Sankar A, Beattie WS, Wijeysundera DN.

Alpha-2 adrenergic agonists for the prevention of cardiac complications

Dallas Duncan1, Ashwin Sankar1, W Scott Beattie2, Duminda N Wijeysundera3

Editorial group: Cochrane Anaesthesia Group.

Data collection and analysis

PLAIN LANGUAGE SUMMARY

Patient or population: adults undergoing non-cardiac surgery

All-cause mortality Study population RR 0.80 14,081 ⊕⊕⊕⊕ -

Cardiac mortality Study population RR 0.86 12,525 ⊕⊕⊕⊕ -

Myocardial infarction Study population RR 0.94 13,907 ⊕⊕⊕⊝ -

Cochrane Database of Systematic Reviews

Bradycardia Study population RR 1.59 14,035 ⊕⊕⊕⊝ -

Summary of findings 2. Alpha-2 adrenergic agonists compared to control in cardiac surgery

Alpha-2 adrenergic agonists compared to control in cardiac surgery

Patient or population: adults undergoing cardiac surgery

Cochrane Database of Systematic Reviews

All-cause mortality Study population RR 0.52 1947 ⊕⊕⊕⊝ -

Acute stroke Study population RR 0.37 1175 ⊕⊕⊝⊝ Total of 18

Bradycardia Study population RR 1.88 1477 ⊕⊕⊕⊝ -

Hypotension Study population RR 1.19 1413 ⊕⊕⊝⊝ -

Cochrane Database of Systematic Reviews

GRADE Working Group grades of evidence

BACKGROUND Why it is important to do this review

Description of the condition Previous systematic reviews of perioperative α-2 adrenergic

Assessment of heterogeneity Sensitivity analysis

imprecision and publication bias (Balshem 2011). The anticipated RESULTS

Figure 1. Study flow diagram.

Included studies Intervention and comparators

Allocation were not described in adequate detail. Concealment of allocation

Cardiac surgery Physiological effects of treatment

Primary outcome 1. Bradycardia requiring pharmacological or pacemaker treatment

2. Myocardial infarction within 30 days after surgery: definition as per

DISCUSSION we are confident that the overall findings of our systematic

Anestesiologica 2013;79(11):1248-58. [EMBASE: 2014029902; Launo 1991 {published data only}

Si 2011 {published data only} Stocche 2004 {published data only}

Yu 2003 {published data only} Biccard 2008

Zalunardo 2002 {published data only} Devereaux 2014b

Guyatt 2008 (POISE trial): a randomised controlled trial. Lancet

Wise 2013 Wijeysundera 2009

Characteristics of included studies [ordered by study ID]

Participants 24 participants undergoing CABG surgery.

Sex: 17 men, 7 women.

Interventions 1. Clonidine 5 μg/kg orally 2 hr before surgery.

Notes Funding: source not disclosed.

Declarations of interest: not stated.

Bias Authors' judgement Support for judgement

Random sequence genera- Unclear risk Not discussed.

Allocation concealment Unclear risk Not discussed.

Blinding of outcome as- Unclear risk Not discussed.

Abi-Jaoude 1993 (Continued)

Incomplete outcome data Low risk All data reported.

Other bias Low risk None.

Sex: 38 men, 12 women.

Outcomes 1. All-cause mortality (30 days).

Notes Funding: Minoufiya University.

Declaration of interest: no conflict of interest.