Clinical Practice Guideline Watch
Revisions include a new recommendation against routine initiation of fixed-dose beta-blockers before noncardiac surgery in low-risk settings.
Sponsoring Organizations: American College of Cardiology, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine, Society for Vascular Surgery
Background and Purpose: In response to publication of the POISE trial results (JW Cardiol May 14 2008), this focused update of the 2007 American College of Cardiology/American Heart Association guidelines addresses the prophylactic use of beta-blockers to minimize cardiac risk during surgery. The update is meant for surgeons, anesthesiologists, patients' primary caregivers, and cardiology consultants. In addition to revised recommendations, the update provides a comprehensive summary of the literature on perioperative beta-blocker therapy.
Key Points:
1. Beta-blockers should be continued in patients undergoing surgery who are currently taking beta-blockers for treatment of indicated conditions (Class I).
2. Beta-blockers titrated to heart rate and blood pressure can be beneficial in patients undergoing vascular surgery who have coronary artery disease or cardiac ischemia identified during preoperative assessment (Class IIa).
3. Beta-blockers titrated to heart rate and blood pressure are reasonable in patients undergoing vascular surgery who have >1 clinical risk factor for CAD identified during preoperative assessment (Class IIa)
4. Beta-blockers titrated to heart rate and blood pressure are reasonable in patients undergoing intermediate-risk surgery who have CAD or >1 clinical risk factor identified during preoperative assessment (Class IIa).
5. In patients undergoing intermediate-risk or vascular surgery with a single clinical risk factor identified during preoperative assessment, the usefulness of beta-blockers is uncertain (Class IIb).
6. In patients undergoing vascular surgery who are not currently taking beta-blockers and have no clinical risk factors, the usefulness of beta-blockers is uncertain (Class IIb).
7. In patients undergoing noncardiac surgery who are not currently taking beta-blockers, routine administration of high-dose, untitrated perioperative beta-blockers is not recommended (Class III).
8. Perioperative withdrawal of beta-blockers should be avoided unless absolutely necessary.
9. In general, beta-blockers should be started well in advance of a planned procedure and carefully titrated perioperatively to achieve adequate heart rate control.
Comment: This focused update elucidates the role of prophylactic perioperative beta-blocker therapy in different clinical scenarios. Patients already taking a beta-blocker should continue taking it. In patients who would benefit from a beta-blocker, it should be started well in advance of the surgical procedure and titrated to heart rate and blood pressure. Beta-blocker therapy should be neither initiated on the day of surgery nor stopped abruptly peri- or postoperatively.
— Joel M. Gore, MD
Published in Journal Watch Cardiology December 16, 2009
Background and Purpose: In response to publication of the POISE trial results (JW Cardiol May 14 2008), this focused update of the 2007 American College of Cardiology/American Heart Association guidelines addresses the prophylactic use of beta-blockers to minimize cardiac risk during surgery. The update is meant for surgeons, anesthesiologists, patients' primary caregivers, and cardiology consultants. In addition to revised recommendations, the update provides a comprehensive summary of the literature on perioperative beta-blocker therapy.
Key Points:
1. Beta-blockers should be continued in patients undergoing surgery who are currently taking beta-blockers for treatment of indicated conditions (Class I).
2. Beta-blockers titrated to heart rate and blood pressure can be beneficial in patients undergoing vascular surgery who have coronary artery disease or cardiac ischemia identified during preoperative assessment (Class IIa).
3. Beta-blockers titrated to heart rate and blood pressure are reasonable in patients undergoing vascular surgery who have >1 clinical risk factor for CAD identified during preoperative assessment (Class IIa)
4. Beta-blockers titrated to heart rate and blood pressure are reasonable in patients undergoing intermediate-risk surgery who have CAD or >1 clinical risk factor identified during preoperative assessment (Class IIa).
5. In patients undergoing intermediate-risk or vascular surgery with a single clinical risk factor identified during preoperative assessment, the usefulness of beta-blockers is uncertain (Class IIb).
6. In patients undergoing vascular surgery who are not currently taking beta-blockers and have no clinical risk factors, the usefulness of beta-blockers is uncertain (Class IIb).
7. In patients undergoing noncardiac surgery who are not currently taking beta-blockers, routine administration of high-dose, untitrated perioperative beta-blockers is not recommended (Class III).
8. Perioperative withdrawal of beta-blockers should be avoided unless absolutely necessary.
9. In general, beta-blockers should be started well in advance of a planned procedure and carefully titrated perioperatively to achieve adequate heart rate control.
Comment: This focused update elucidates the role of prophylactic perioperative beta-blocker therapy in different clinical scenarios. Patients already taking a beta-blocker should continue taking it. In patients who would benefit from a beta-blocker, it should be started well in advance of the surgical procedure and titrated to heart rate and blood pressure. Beta-blocker therapy should be neither initiated on the day of surgery nor stopped abruptly peri- or postoperatively.
— Joel M. Gore, MD
Published in Journal Watch Cardiology December 16, 2009
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