Perioperative Beta Blocker

Criteria not met for AHA 2009 guidelines
1. Revised Cardiac Index of 3 or more and
2. 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

Perioperative Beta Blockers reduced cardiac events but were associated with more strokes and a higher mortality (POISE Trial)
1. Increased adverse events appear to be associated with Hypotension due to recently started Beta Blocker
2. For those on Beta Blockers at least 4 weeks, Cardiovascular Risk and mortality was decreased
References
1. Devereaux (2008) Lancet 371(9627): 1839-47 [PubMed]
2. Rosenman (2008) Mayo Selected Topics in Internal Medicine, Lecture

AHA guidelines (2009) modified indications for Perioperative Beta Blockers reflect adverse effects as above
Continue Beta Blockers if already started (chronic use)
1. Myocardial Infarction in the last 2-3 years
2. Compensated Systolic Heart Failure
Starting Perioperative Beta Blocker
1. Contraindications
  1. See contraindications above
  2. Do not start a Preoperative Beta Blocker without careful consideration
    1. Avoid perioperatively starting Beta Blockers in lower risk patients (more adverse events)
  3. Lindenauer (2005) N Engl J Med 353(4): 349-61 [PubMed]
2. Indications to start Beta Blocker
  1. Moderate to High Risk Surgery and Revised Cardiac Index of 3 or more or
  2. Vascular surgery with a positive stress test
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 30 days after surgery
Indications to use half dose of Beta Blocker
1. Small, elderly or frail patient
2. Systolic Blood Pressure < 110 mmHg
3. Heart Rate <65 beats per minute
Indications to hold dose
1. Heart Rate <50 beats per minute
Indications to increase dose
1. Heart Rate >80
References
1. Fleischmann (2009) J Am Coll Cardiol 54:2102-28 [PubMed]

Modify dosing as per protocol above
Metoprolol (succinate or XL is preferred)
1. Metoprolol Succinate (Toprol XL)
  1. Standard dose: 100 mg orally daily until 14 days post-surgery
  2. Small, frail or elderly: 50 mg orally daily if indicated per protocol above
2. Metoprolol Tartrate
  1. Standard dose: 50 mg orally twice daily until 14 days post-surgery
  2. Small, Frail or elderly: 25 mg orally twice daily
3. Lopressor IV
  1. Standard dose: 10 mg IV q6 hours if unable to take oral
  2. Small, frail or elderly: Use 5 mg IV q6h if indicated per protocol above
  3. Convert to oral when able
  4. Continue for 14 days post-surgery
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
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
References
1. Poldermans (1999) N Engl J Med 341:1789-94 [PubMed]