- There continues to be much debate on Beta Blockade preoperatively. Guidelines have become increasingly more reserved in their recommendations for Beta Blocker use.
- However, the majority of geriatric patients undergoing surgery will benefit from perioperative B-blockers because of comorbid conditions and not age alone.
- We CONTINUE beta blockers in patients taking them for indications such as hypertension, rate control for atrial fibrillation, control of angina, heart failure, or prior myocardial infarction (MI).
- However, despite their ability to lower the risk of perioperative MI, we do not start beta blockers preoperatively in patients without these indications, as they may increase the risk of death and stroke.
What Beta Blocker and How Much ?
- All studies that have reported a cardiovascular benefit of perioperative beta blockers have used agents that are moderately (atenolol or metoprolol) or highly (bisoprolol) beta-1 cardioselective.
- The optimal preoperative heart rate and blood pressure for any patient receiving long-term beta blocker therapy is not known. We suggest that the resting heart rate be between 60 and 70 beats per minute. Some of our experts hold the dose on the morning of surgery if the systolic blood pressure is <115 mmHg and half the dose if it is between 116 and 130 mmHg.
Auerbach AD, Goldman L. β-Blockers and Reduction of Cardiac Events in Noncardiac Surgery: Scientific Review. JAMA. 2002;287
Beta Blocker Examples
- Atenolol starting dose-12.5, max dose -100 mg q d
- bisoprolol starting dose-2.5 gm/d, max dose– 20 mg/d
- metoprolol starting dose- 12.5-25 bid, maximum dose- -400 mg/d, ( use XL when possible)
- Initiation; > 24 hours preop, Best-7-30 days pre procedure
- Titrate to HR 60-70 BPM (and avoid if BP < 100 syst.)
- Use long-acting beta-blocker when possible.
- Continue postoperatively (Most protocols continue for at least 30 days post-op )
- Do Not start beta-blocker therapy on the day of surgery in beta-blocker naïve patients.