CardioExchange Archive

By now, there’s a good chance you’ve heard that the American College of Cardiology and the American Heart Association updated their guidelines on the perioperative use of beta-blockers in patients who undergo noncardiac surgery. Perhaps you’ve been thinking about the implications for practice. I certainly have, but then again I chaired the group that wrote the update, and I’d like to share my own reflections, which don’t necessarily represent the official stance of the ACC or the AHA.

The challenge in this update was to reconcile sometimes conflicting new data, most notably from the POISE and DECREASE-IV trials, to produce a clinically relevant document for guiding clinicians in this area. First, here are a few of the key points from the update:

• Continue beta-blockers in noncardiac surgery patients who are already receiving them appropriately (class I recommendation). Discontinuation of beta-blockade is not recommended.
• It’s reasonable to consider beta-blockers in high-risk patients (e.g., those with known coronary disease or multiple risk factors for cardiac complications) who are undergoing intermediate- or high-risk surgeries (class IIa recommendation). In general, the fewer risk factors the patient has, the less strong the case for using perioperative beta-blockade.
• When starting beta-blockers in advance of an elective procedure, (1) allow sufficient time for titration to heart rate and blood pressure, as tolerated preoperatively and throughout the perioperative period; and (2) maintain vigilance for hypovolemia, infection, or other potential causes of tachycardia that may require adjustment, or even discontinuation, of beta-blocker therapy.
• Routine perioperative use of beta-blockers is not recommended, particularly not fixed, higher-dose regimens started on the day of surgery.

The new guidelines support much of what I was already doing in the clinic for elective, noncardiac surgery patients who were at risk for cardiac complications: weighing the pros and cons of beta-blocker therapy, initiating it “low and slow,” and adjusting up from there. However, the POISE study further clarified that beta-blockers can be associated with risk in this clinical setting, particularly in fixed, higher-dose regimens started on the day of surgery. The onus is on us as clinicians to select patients for therapy — and monitor them — thoughtfully.

By the way, the European Society of Cardiology also recently issued its guidelines on perioperative care for patients undergoing noncardiac surgery.. The recommendations, which are worth your time to review, differ in some respects from ours (e.g., the ESC has three class I indications for beta-clockers, whereas we have only one). However, I believe that the core message to clinicians is similar: Choose patients judiciously, start therapy well in advance of elective procedures, adjust as tolerated, and monitor patients carefully.

So, let me ask, how are you using beta-blockers perioperatively in the wake of the new data? What “clinical pearls” can you share from your experiences? And what are you telling your patients about what’s changed and what hasn’t? I’m curious to hear, and undoubtedly so are your colleagues.