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Medical Therapy - Peri-Operative Beta Blockade (Revised 2010)

2009 ACCF/AHA Focused Update on Perioperative Beta Blockade*

The 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery were published prior to the release of the results of the POISE (Perioperative Ischemic Evaluation) trial. Although this study confirmed the beneficial effect of perioperative beta blockade in terms of reduced cardiovascular death, myocardial infarction and cardiac arrest, there was an increase risk of stroke and total mortality, likely secondary to the associated hypotension and bradycardia. Consequently, the issue of perioperative beta-blockade has been revisted by the ACC/AHA and their conclusions have been incorporated into a focused update of the 2007 guidelines.

After reviewing the new information that is presently available, the committee /task force concluded the following:

  1. There is a Class 1 indication (ie, the treatment SHOULD be administered) for the perioperative continuation of beta blockers in patients already taking these medications.
  2. That it is reasonable to initiate perioperative beta blockade for patients with inducible ischemia, coronary artery disease or multiple clinical risk factors who are undergoing vascular (high risk) surgery.
  3. Perioperative beta blockade should be considered in patients with coronary artery disease or multiple risk factors who are undergoing intermediate risk surgery.
It is important to understand that the initiation of therapy must be started well in advance of the surgery. Doses must be carefully titrated to achieve an adequate reduction of heart rate without frank bradycardia or hypotension. A reasonable goal is a heart rate of 50 - 60 bpm. This titration needs to be continued throughout the preoperative, intraoperative and postoperative periods.

The guidelines further stipulate that the routine administration of perioperative beta blockers starting on the day of surgery is ill advised, particularly in the higher fixed dose regimens.

The task force also strongly recommends that withdrawal of beta-blockers in the perioperative period should be avoided unless necessary. Abrupt discontinuation has been associated with an increase risk of MI, chest pain and 1 year mortality. Continuation of therapy throughout the perioperative is a Class 1 indication.

*Click here to access the 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade: A Report of the American College of Cariology Foundation/American Heart Assoication Task Force on Practice Guidelines. The article is available to download in PDF format. 


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