Perioperative Beta Blocker

Aka: Perioperative Beta Blocker

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