We’ve addressed the issue of perioperative beta blocker use in multiple columns (see Patient Safety Tips of the Week for November 20, 2007 “New Evidence Questions Perioperative Beta Blocker Use” and November 4, 2008 “Beta Blockers Take More Hits”). The American College of Cardiology Foundation and American Heart Association have now updated their ACC/AHA guidelines on perioperative use of beta blockers.
The only remaining Class I recommendation is that beta blockers be continued in patients already taking them for angina, arrhythmias, hypertension or other ACC/AHA class I guideline indications.
The major new recommendation is that routine administration of high-dose beta blockers in the absence of dose titration is not useful and may be harmful to patients not currently taking beta blockers who are undergoing noncardiac surgery.
They also downgraded the levels of supportive evidence for use of perioperative beta blockers in patients in whom preoperative assessment identifies coronary heart disease or high cardiac risk who are undergoing intermediate-risk or vascular surgery (though the recommendations still use the term “probably recommended”).
Note, however, that all the recommendations carefully use the wording “Beta blockers titrated to heart rate and blood pressure”. You’ll recall that critics of the POISE trial attributed the negative influence of beta blockers (stroke and death) to the fact that the beta blockers in that study were not titrated to blood pressure and heart rate.
The perioperative beta blocker controversy is not over yet. Proponents of their use (eg. Poldermans et al 2009) continue to focus on the need for careful titration of dose, timing, specific beta blocker, and issues such as withdrawal of beta blockers. The controversy is not likely to be resolved until a study like POISE is repeated, using that titrated dose approach to perioperative beta blockers.
Update: See also our November 2010 What’s New in the Patient Safety World column “More Perioperative Beta Blocker Controversy”
Fleisher LA, Beckman JA, Brown KA, et al.for the American College of Cardiology Foundation, American Heart Association Task Force on Practice Guidelines, 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. 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. J. Am. Coll. Cardiol. 2009, first published on Nov 2, 2009 as doi: doi:10.1016/j.jacc.2009.07.010
Poldermans, Don; Schouten, Olaf; van Lier, Felix; Hoeks, Sanne E.; van de Ven, Louis; Stolker, Robert Jan; Fleisher, Lee A. Perioperative Strokes and Beta Blockade. Anesthesiology 2009. 111(5): 940-945, November 2009.