ACC, AHA Update Guidelines for Beta Blockers
Therapy Should be Started Well in Advance of Elective, Noncardiac Surgery
By News Staff
The use of beta blockers in patients undergoing noncardiac surgeries should be initiated well in advance of procedures and titrated up as blood pressure and heart rate allow, according to an update of guidelines from the American College of Cardiology, or ACC, and the American Heart Association, or AHA.
Kirsten Fleischmann, M.D., M.P.H., associate professor of medicine at the University of California-San Francisco and chair of the group that reviewed new evidence on the perioperative use of beta blockers, said in a news release that physicians must be vigilant in assessing patients' cardiac risk and weighing that risk against potential side effects of therapy.
"These updated guidelines are intended to provide guidance for the appropriate use of beta blockers to help reduce the risk of cardiac complications," Fleischmann said.
The ACC and AHA released guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery just two years ago. However, the organizations released a focused update last month, prompted by results of a study in which fixed, higher doses of the beta blocker metoprolol were started in more than 8,000 patients on the day of noncardiac surgery.
That study confirmed a reduction in cardiac events, including cardiovascular death, myocardial infarction and cardiac arrest, with perioperative beta-blocker therapy. However, the benefit was offset by an increased risk of stroke and total mortality.
The ACC and AHA said the findings "suggest that routine administration of high-dose beta blockers in the absence of dose titration is not useful and may be harmful to beta-blocker-naive patients undergoing surgery."
The organizations said evidence suggests that when possible and where indicated, beta blockers should be started days to weeks before elective surgery. Furthermore, the dose should be titrated to achieve adequate heart rate control to increase the likelihood that the patient will receive the benefit of the medication while minimizing the risks of hypotension and bradycardia.
The updated guidelines did not change the organizations' recommendation to continue beta blockers perioperatively in patients who are already receiving them. The ACC and AHA advise that beta blockers are reasonable to consider in
"These updated guidelines are intended to provide guidance for the appropriate use of beta blockers to help reduce the risk of cardiac complications," Fleischmann said.
The ACC and AHA released guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery just two years ago. However, the organizations released a focused update last month, prompted by results of a study in which fixed, higher doses of the beta blocker metoprolol were started in more than 8,000 patients on the day of noncardiac surgery.
That study confirmed a reduction in cardiac events, including cardiovascular death, myocardial infarction and cardiac arrest, with perioperative beta-blocker therapy. However, the benefit was offset by an increased risk of stroke and total mortality.
The ACC and AHA said the findings "suggest that routine administration of high-dose beta blockers in the absence of dose titration is not useful and may be harmful to beta-blocker-naive patients undergoing surgery."
The organizations said evidence suggests that when possible and where indicated, beta blockers should be started days to weeks before elective surgery. Furthermore, the dose should be titrated to achieve adequate heart rate control to increase the likelihood that the patient will receive the benefit of the medication while minimizing the risks of hypotension and bradycardia.
The updated guidelines did not change the organizations' recommendation to continue beta blockers perioperatively in patients who are already receiving them. The ACC and AHA advise that beta blockers are reasonable to consider in
- patients at high risk for heart attacks or other cardiac complications because of abnormal stress test results or known coronary artery disease who undergo vascular surgery; and
- high-risk patients undergoing intermediate risk surgery or in those with multiple risk factors for complications, such as diabetes, a history of heart failure or significant kidney disease, who undergo vascular surgery.
