II. Indications
III. Contraindications
- Criteria not met for AHA 2009 guidelines
- Revised Cardiac Index of 3 or more and
- Intermediate to High Risk Surgery
- Emergent surgery
- Beta Blocker allergy
- Bradycardia (resting Heart Rate <60)
- Second degree AV Heart Block (unless paced)
- Severe Obstructive Lung Disease
IV. Adverse Effects
- Perioperative Beta Blockers reduced cardiac events but were associated with more strokes and a higher mortality (POISE Trial)
- Increased adverse events appear to be associated with Hypotension due to recently started Beta Blocker
- For those on Beta Blockers at least 4 weeks, Cardiovascular Risk and mortality was decreased
- References
- Devereaux (2008) Lancet 371(9627): 1839-47 [PubMed]
- Rosenman (2008) Mayo Selected Topics in Internal Medicine, Lecture
V. Protocol
- AHA guidelines (2009) modified indications for Perioperative Beta Blockers reflect adverse effects as above
- Continue Beta Blockers if already started (chronic use)
- Myocardial Infarction in the last 2-3 years
- Compensated Systolic Heart Failure
- Starting Perioperative Beta Blocker
- Contraindications
- See contraindications above
- Do not start a Preoperative Beta Blocker without careful consideration
- Avoid perioperatively starting Beta Blockers in lower risk patients (more adverse events)
- Lindenauer (2005) N Engl J Med 353(4): 349-61 [PubMed]
- Indications to start Beta Blocker
- Moderate to High Risk Surgery and Revised Cardiac Index of 3 or more or
- Vascular surgery with a positive stress test
- 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 30 days after surgery
- Contraindications
- Indications to use half dose of Beta Blocker
- Small, elderly or frail patient
- Systolic Blood Pressure < 110 mmHg
- Heart Rate <65 beats per minute
- Indications to hold dose
- Heart Rate <50 beats per minute
- Indications to increase dose
- Heart Rate >80
- References
VI. Preparations
- Modify dosing as per protocol above
-
Metoprolol (succinate or XL is preferred)
- Metoprolol Succinate (Toprol XL)
- Standard dose: 100 mg orally daily until 14 days post-surgery
- Small, frail or elderly: 50 mg orally daily if indicated per protocol above
- Metoprolol Tartrate
- Standard dose: 50 mg orally twice daily until 14 days post-surgery
- Small, Frail or elderly: 25 mg orally twice daily
- Lopressor IV
- Standard dose: 10 mg IV q6 hours if unable to take oral
- Small, frail or elderly: Use 5 mg IV q6h if indicated per protocol above
- Convert to oral when able
- Continue for 14 days post-surgery
- Metoprolol Succinate (Toprol XL)
-
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
VII. Resources
- ACC/AHA 2014 Guideline on Perioperative Cardiovascular Evaluation and Management
- ACC/AHA 2014 Guideline on Perioperative Beta Blockade