Reducing Perioperative Cardiac Risk:Beta Blockers

Terry Shaneyfelt, MD, MPHAssoc. Professor, UAB Department of Medicine

Devereaux PJ et al., CMAJ 2005; 173:627

Academic Impropriety

Bouri et al. Heart published online first July 31, 2013

• Bouri et al

• Wijeysundera et al for the updated ACC/AHA perioperative cardiac eval and mgmt guidelines (Circulation published online Aug 1, 2014)

2 recent systematic reviews on beta-blockers have similar findings

Mortality Increased

ACC/AHA review also found increased mortality

Non-fatal MI Reduced

ACC/AHA review also found reduced non-fatal MI

Stroke Increased

ACC/AHA review also found increased strokes

Perioperative Strokes are Devastating!

Do Higher Risk Patients Benefit From β-Blockers?

What About Vascular Surgery Patients?London et al. JAMA 2013;309:1704

POISE Investigators. Lancet (published online May 13, 2008)

• Class I• BB should be continued in patients on them chronically

• Class IIb• In pts with intermediate or high risk ischemia noted on

preop testing reasonable to begin BB• In pts with RCRI ≥ 3 reasonable to begin BB• Begin more than 1 day prior to surgery

• Class III (Harm)• BB should not be started on day of surgery

ACC/AHA guidelines 2014

• If they are initiated:• Heart rate 60-70 bpm• SBP > 115-120 mm Hg• Start more than 1 day prior to surgery• ? Titration• ? Which one to choose

Should Patients Be Prescribed β-Blockers Perioperatively?