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perioperative beta blockade

Iperioperative beta-blockade (for non-cardiac surgery) Indications: 1) patients currently taking beta-blocker for any class 1 indication (heart failure, angina, symptomatic arrhythmia, hypertension) [4,9] 2) preoperative myocardial ischemia [4,8] - class 1 indication for vascular surgery 3) may benefit patients at high risk of cardiovascular disease a) known coronary artery disease [8] b) at least 2 of the following: [7] 1] diabetes mellitus 2] previous stroke or TIA 3] serum creatinine >= 2 mg/dL 4] aortic or aortoiliac surgery 4) may benefit patients with with a) heart failure b) recent myocardial infarction [11] 5) vascular surgery in patients with coronary artery disease [7] Contraindications: 1) heart rate < 55/min 2) systolic blood pressure < 100 mm Hg 3) decompensated heart failure 4) bronchospasm 5) third degree AV block [7] 6) routine use of high-dose beta-blockers without dose titration is not helpful & may be harmful to cardiac-surgery patients naive to beta-blockers [8] 7) perioperative beta-blocker to prevent atrial fibrillation a) not necessary for patients with ventricular rate < 110/min [17] b) perioperative amiodarone 10 mg/kg 6 days prior to & 6 days post-op reduces postoperative atrial fibrillation after cardiac surgery by 50% c) metoprolol as effective in preventing atrial fibrillation as amiodarone [18] 8) patients at low cardiovascular risk [1,5] Pathology: - risk of major cardiovascular events reduced at expense of increased risk of bradycardia & hypotension [2] - metoprolol succinate started hours before surgery lowers incidence of myocardial infarction at the expense of increased mortality Management: 1) continue beta-blockers for patients currently taking them for any class 1 indication (heart failure, angina, symptomatic arrhythmia, hypertension) [4,9,13] 2) titrate to a perioperative heart rate of 50-70 beats a) start titration 1 week to 1 month prior to surgery b) bisoprolol 2.5 mg QD started 1 month prior to surgery, confers reduction of 30-day cardiac death & nonfatal MI [6] c) IV bisoprolol may be used intraoperatively [12] 3) perioperative beta-blocker on the day of or day after non cardiac, non vascular surgery is associated with lower 30 day mortality at 30 days (RR=0.73) [10] a) benefit limited to patients with 2 or more RCRI (Revised Cardiac Risk Index) factors b) with 2 RCRI factors, RR=0.63 c) with 4 RCRI factors, RR=0.40 d) reduced mortality only in those with >= 3 risk factors - with 3 or 4 risk factors RR=0.63 [14] - risk factors: renal failure, coronary artery disease, diabetes, & surgery in a major body cavity - mortality is increased in patients with no risk factors (RR=1.19) [14] e) no benefit in patients undergoing vascular surgery 4) outcomes may be better with atenolol than metoprolol because of longer 1/2life [3] 5) perioperative beta-blockers can reduce postoperative supraventricular arrhythmias & ventricular arrhythmias after cardiac surgery [16]

General

perioperative management

References

  1. Lindenauer PK, Pekow P, Wang K, Mamidi DK, Gutierrez B, Benjamin EM. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005 Jul 28;353(4):349-61. PMID: 16049209
  2. Devereaux PJ, Beattie WS, Choi PT, Badner NH, Guyatt GH, Villar JC, Cina CS, Leslie K, Jacka MJ, Montori VM, Bhandari M, Avezum A, Cavalcanti AB, Giles JW, Schricker T, Yang H, Jakobsen CJ, Yusuf S. How strong is the evidence for the use of perioperative beta blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials. BMJ. 2005 Aug 6;331(7512):313-21. Epub 2005 Jul 4. Review. PMID: 15996966
  3. Redelmeier DA et al. beta-Blockers for elective surgery in elderly patients: Population based, retrospective cohort study. BMJ 2005 Oct 22; 331:932-4 PMID: 16210252
  4. Fleisher LA et al, Perioperative beta-blocker therapy American College of Cardiology (ACC) and the American Heart Association (AHA) http://www.acc.org/clinical/guidelines/perio/periobetablocker.pdf
  5. Prescriber's Letter 13(8): 2006 Perioperative Beta-Blockers Detail-Document#: 220803 (subscription needed) http://www.prescribersletter.com
  6. Dunkelgrun M et al Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: A randomized controlled trial (DECREASE-IV). Ann Surg 2009 Jun; 249:921. PMID: 19474688
  7. Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 18, American College of Physicians, Philadelphia 2006, 2012, 2018.
  8. Fleischmann KE et al for the 2009 Writing Group to Review New Evidence and Update the 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade A Report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines http://content.onlinejacc.org/cgi/reprint/j.jacc.2009.07.004v1.pdf - Fleisher LA, Beckman JA, Brown KA et al 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American college of cardiology foundation/ American heart association task force on practice guidelines. Circulation. 2009 Nov 24;120(21):e169-276. PMID: 19884473 - Prescriber's Letter 16(12): 2009 Perioperative Beta-Blockers: Updated Recommendations COMMENTARY: Perioperative Beta-Blockers: Updated Recommendations GUIDELINES: ACCF/AHA Guideline on Perioperative Beta-Blockers Detail-Document#: 251208 (subscription needed) http://www.prescribersletter.com
  9. Kwon S et al. Beta-blocker continuation after noncardiac surgery: A report from the Surgical Care and Outcomes Assessment Program. Arch Surg 2012 May; 147:467 PMID: 22249847 http://archsurg.jamanetwork.com/article.aspx?articleid=1150110
  10. London MJ et al Association of Perioperative beta-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery. JAMA. 2013;309(16):1704-1713. PMID: 23613075 http://jama.jamanetwork.com/article.aspx?articleid=1681412
  11. Andersson C Association of Beta-Blocker Therapy With Risks of Adverse Cardiovascular Events and Deaths in Patients With Ischemic Heart Disease Undergoing Noncardiac Surgery. A Danish Nationwide Cohort Study. JAMA Intern Med. Published online November 18, 2013 PMID: 24247428 http://archinte.jamanetwork.com/article.aspx?articleid=1779729 - Whelton SP and Bansal S Perioperative Beta-Blockers Revisited. Good for What Ails You? JAMA Intern Med. Published online November 18, 2013. PMID: 24247215 http://archinte.jamanetwork.com/article.aspx?articleid=1779725
  12. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  13. Richman JS et al. Improved outcomes associated with a revised quality measure for continuing perioperative beta-blockade. JAMA Surg 2014 Oct; 149:1031 PMID: 25141795 http://archsurg.jamanetwork.com/article.aspx?articleid=1893805
  14. Friedell ML et al beta-Blockade and Operative Mortality in Noncardiac Surgery. Harmful or Helpful? JAMA Surg. Published online May 27, 2015 PMID: 26017188 http://archsurg.jamanetwork.com/article.aspx?articleid=2294293
  15. Wijeysundera DN, Duncan D, Nkonde-Price C et al Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec 9;130(24):2246-64. Review. PMID: 25085964 Free Article
  16. Blessberger H, Kammler J, Domanovits H et al. Perioperative beta-blockers for preventing surgery-related mortality and morbidity. Cochrane Database Syst Rev. 2014;(9):CD004476 PMID: 25233038
  17. January CT, Wann LS, Alpert JS et al 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. March 28, 2014 PMID: 24682348 http://circ.ahajournals.org/content/early/2014/03/26/CIR.0000000000000040.full.pdf+html - January CT,Wann LS, Alpert JS et al 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. March 28, 2014 PMID: 24682347 http://circ.ahajournals.org/content/early/2014/03/27/CIR.0000000000000041.full.pdf+html
  18. Halonen J et al. Metoprolol versus amiodarone in the prevention of atrial fibrillation after cardiac surgery: A randomized trial. Ann Intern Med 2010 Dec 7; 153:703 PMID: 21135293