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Perioperative Beta Blocker
Aka: Perioperative Beta Blocker
- See Also
- Preoperative Examination
- Preoperative Cardiovascular Evaluation
- Beta Blocker
- Metoprolol
- Indications
- See Preoperative Cardiovascular Evaluation
- Cardiac Risk Factors and not Low Risk Surgery
- Efficacy
- Reduces cardiac perioperative mortality by 65%
- Adverse Effects
- Perioperative Beta Blockers were associated with more strokes and a higher mortality (POISE Trial)
- Likely related to Hypotension
- Devereaux (2008) Lancet 371(9627): 1839-47
- Rosenman (2008) Mayo Selected Topics in Internal Medicine, Lecture
- Protocol
- AHA guidelines (2009) modified indications for Perioperative Beta Blockers reflect adverse effects as above
- Continue Beta Blockers if already started (chronic use)
- Do not start a preoperative Beta Blocker without careful consideration
- Indicated for Higher cardiovascular risk with Revised Cardiac Index of 3 or more
- Avoid perioperatively starting Beta Blockers in lower risk patients (more adverse events)
- Lindenauer (2005) N Engl J Med 353(4): 349-61
- Initiate early (at least 2-4 weeks before surgery)
- Titrate to Heart Rate of 60-80 and avoid Hypotension
- Monitor preoperatively after starting
- Continue Beta Blocker for at least 14 days after surgery
- Indications to use half dose of Beta Blocker
- Small, elderly or frail patient
- Systolic Blood Pressure < 100 mmHg
- Heart Rate <65 beats per minute
- Indications to hold dose
- Heart Rate <50 beats per minute
- Preparations
- Modify dosing as per protocol above
- Metoprolol (preferred)
- Oral: 50 mg PO bid until 14 days post-surgery
- Use 25 mg PO bid if indicated per protocol above
- IV: 10 mg IV q6 hours if unable to take oral
- Use 5 mg IV q6h if indicated per protocol above
- Convert to oral when able
- Continue for 14 days post-surgery
- Atenolol (older protocol, see protocol above)
- Initial dose: 5 mg IV 30 minutes before surgery
- Next dose: 5 mg IV immediately after surgery
- Maintenance: 50-100 mg PO qd for 7 days
- Bisoprolol (older protocol, see protocol above)
- Dose: 5-10 mg PO qd
- Start 7 days before surgery
- Continue for 30 days after surgery
- References
- Poldermans (1999) N Engl J Med 341:1789-94