ACC/AHA Say Don't Start Beta-Blockers on Day of Surgery
By Peggy Peck, Executive Editor, MedPage Today
Published: November 02, 2009
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
§ Explain to interested patients that the updated guidelines released today are based on evidence from randomized, clinical trials and therefore should be used when making clinical decisions.
High-risk patients who are not taking beta-blockers should have beta-blocker therapy started well before scheduled cardiovascular surgery, with doses titrated up as the surgery date approaches, according to updated guidelines released today by the American College of Cardiology and American Heart Association.
Surgery patients who are already taking beta-blockers should not have their dose titrated up on the day of surgery, according to the update, published online by the Journal of the American College of Cardiology and Circulation, Journal of the American Heart Association.
Standard practice for cardiovascular surgery had been to initiate beta-blocker therapy on the day of the procedure or to pump up the dose right before it in order to minimize cardiovascular risks associated with the stress of surgery.
But data from the POISE trial (Perioperative Ischemic Evaluation), prompted the ACC/AHA to revisit the issue, according to Kirsten E. Fleischmann, MD, MPH, who chaired the group that drafted the update.
Fleischmann said the new guidelines do not alter the current recommendation to continue beta-blockers perioperatively in those patients who are already receiving them.
She said the "guidelines do not advocate for routine administration of beta-blockers, particularly in higher fixed-dose regimens, begun on the day of surgery based on data from the POISE study."
In the POISE trial, patients taking beta-blockers had a lower risk of perioperative myocardial infarction and/or primary cardiac event, but they had a higher risk of stroke and overall mortality.
The work group also agreed that beta-blockers were reasonable to consider in the following:
- Patients at high risk for heart attacks or other cardiac complications because of abnormal stress test results or known coronary artery disease who undergo vascular surgery
- High-risk patients undergoing intermediate-risk surgery or in those with multiple risk factors for complications (e.g., diabetes, a history of heart failure, significant kidney disease) who undergo vascular surgery
The role of beta-blockers in lower-risk patients or in patients undergoing lower-risk surgeries such as percutaneous interventions remains unclear. The guidelines committee said the decision to use beta-blockers in those instances "requires careful consideration of the risks and benefits."
Finally, the group affirmed that beta-blockers should not be initiated in patients who "have absolute contraindications to beta blockage."