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1.7: PERIOPERATIVE BETA BLOCKADE

Last updated

Dec 16, 2021
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- 1.6: CARDIOVASCULAR DISEASE
- 1.8: RESPIRATORY DISEASE

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Previous controlled studies with nitrates, calcium channel blockers, clonidine and digoxin have not demonstrated protection from myocardial ischaemia intra- or postoperatively.

Recent studies suggest that giving beta-blockers perioperatively may reduce the risk of cardiac complications and death in patients having major non-cardiac surgery. The greatest benefit would seem to be for those patients at high risk of perioperative cardiac complications having major surgery.

Contraindications

Beta-blockade should not be used in patients who have a resting heart rate less than 60 beats/minute or who have asthma requiring regular treatment.

Choice of Beta-blocker

If possible, beta-1 selective beta-blockers should be used. Non-selective beta-blockers are more likely to produce respiratory complications such as bronchospasm.At this stage no evidence suggests any particular beta-1 blocker is better.

Management

The beta-blocker should be started as soon as possible before the surgery in high-risk patients (even up to a month before) so that the dose can be changed to achieve a resting heart rate of 50 to 60 beats/minute. Even if the anesthetist is unable to start beta blockade in the weeks before surgery, there may still be a benefit in giving a beta- blocker on induction of anaesthesia. The beta-blocker should be given in small doses to avoid a fall in blood pressure of greater than 20%.The beta-blocker should be continued after surgery at least as long as the patient remains in hospital.

High Risk Factors

Patient risk factors for perioperative myocardial infarction include:

previous myocardial infarction or angina, diabetes
major surgery (intraabdominal, intrathoracic, vascular)
congestive heart failure
renal impairment due to vascular disease or diabetes
poor exercise tolerance (unable to walk up 2 flights of stairs or 400 metres on flat ground).

Recommendation

Giving beta-blockers perioperatively may reduce the risk of cardiac complications anddeath in patients having major non-cardiac surgery.

High-risk patients are those with 3 or more of the above risk factors or myocardialinfarction within the previous 6 months or angina increasing in severity or of recentonset. A cardiologist should review them before surgery.

Low to moderate risk patients have only 1 or 2 of the above risk factors present andshould be treated with beta-blockers at least one week before major surgery aiming for aresting heart rate of less than 60 bpm.

Contraindications

Choice of Beta-blocker

Management

High Risk Factors

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