Updates on Perioperative Beta-Blocker Use in Noncardiac Surgery

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US Updates Advice on Perioperative Beta-Blocker Use in Noncardiac Surgery

November 10, 2009 — The American College of Cardiology ( ACC) and the American Heart Association (AHA) have released their much-awaited focused update on the perioperative use of beta-blockers for noncardiac surgery [1].

The new document provides specific recommendations about which patients will likely benefit from beta blockade in this setting and in which patients there is not enough evidence to recommend their use. This comes on the heels of the first-ever European Society of Cardiology (ESC) guidelines on the management of cardiac risk in noncardiac surgery.

This is an increasingly important topic--cardiac events are the major cause of morbidity and mortality in patients undergoing noncardiac surgery, and cardiologists are constantly faced with decisions about how to reduce the risk of these events without unnecessarily delaying surgery.

The specific issue of whether to use beta-blockers perioperatively in such patients has been extremely controversial in the past few years, mostly due to conflicting data from two large clinical trials, Perioperative Ischemic Evaluation (POISE) and DECREASE-IV [2].

The Higher the Risk, the More Benefit to Be Gained From Beta-Blockers Fleischmann said the US update incorporates important new information, "most notably from POISE and DECREASE IV," which were published after the initial 2007 full ACC/AHA guidelines on perioperative care.

Advice that stays the same, however, is that patients already taking beta-blockers should continue to receive them; this remains a class I indication, she noted.

But in addition, she says, there are now several class IIa recommendations: "It is reasonable to consider beta-blockers for patients at high cardiac risk--for example, due to known coronary artery disease, inducible ischemia on preoperative testing, or multiple clinical risk factors--who are undergoing intermediate or high-risk surgery. "In general, the higher the risk from a cardiovascular standpoint, the more likely a patient will benefit from beta-blockers," she explains.

But Routine Use Is a No-No However,

she says, "The POISE results make clear that starting higher doses of beta-blockers acutely on the day of surgery is associated with risk." Therefore, routine administration of beta-blockers perioperatively, particularly in higher, fixed-dose dosing regimens, "is not advocated," she stresses.

"The update recommends careful consideration of the risk/benefit ratio for each patient and dose adjustment and titration to heart rate and blood pressure," she reiterates.

The update, which was developed in collaboration with the 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, and Society for Vascular Surgery, was published online November 2, 2009 in the Journal of the American College of Cardiology and Circulation; it will also be published in the November 24, 2009, issues of the journals.

References

1. Fleischmann KE, Beckman JA, Buller CE, et al. 2009 ACCF/AHA focused update on perioperative beta blockade. A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol 2009; DOI:10.1016/j.jacc.2009.07.004. Available at: http://content.onlinejacc.org. Circulation 2009: DOI: 10.1161/CIRCULATIONAHA.109.192690. Available at: http://circ.ahajournals.org.

2. Dunkelgrun M, Boersma E, Schouten O, et al. Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: a randomized controlled trial (DECREASE-IV). Ann Surg 2009; 249:921-926.Abstract

Clinical Context

In the United States, more than 30 million noncardiac surgeries are performed annually. Cardiac events occurring perioperatively in patients undergoing noncardiac surgery occur relatively often and can be associated with significant morbidity and mortality rates, as well as longer hospital stays and increased costs. Any surgery, especially high-risk procedures, can cause cardiac stress, particularly for patients at increased cardiovascular risk.

Beta-blockers may help protect against perioperative myocardial infarction by reducing heart rate and offsetting the effects of stress hormones on the heart.

The ACC and the AHA updated 2007 Practice Guidelines concerning the potential benefits and harms of beta-blocker use to reduce cardiac events during noncardiac surgeries.

The new, evidence-based guidelines offer specific recommendations concerning clinical situations in which patients are likely to benefit from perioperative use of beta-blockers and those situations in which evidence is insufficient to recommend use.

Clinical Implications

• Patients at greatest cardiovascular risk are most likely to benefit from perioperative use of beta-blockers for noncardiac surgery, according to ACC/AHA revised guidelines. Beta-blocker therapy may be helpful in patients selected based on clinical and surgical risk.

• Patients not at increased cardiovascular risk are less likely to benefit from perioperative use of beta-blockers for noncardiac surgery. Starting higher doses of beta-blockers acutely on the day of surgery may be harmful. Careful patient selection, dose adjustment, and monitoring during the perioperative period are essential.