Beta blockers
The 2024 AHA/ACC guideline recommends continuing established beta-blocker therapy through the perioperative period, with adjustments according to clinical circumstances.
Starting a new beta blocker
For a new indication, AHA/ACC 2024 favours starting sufficiently before elective surgery—optimally more than 7 days—to assess tolerability and titrate treatment. It advises against starting on the day of surgery when there is no immediate indication, because of potential harm.
Evidence context
This caution reflects trial evidence, notably POISE (2008), in which high-dose extended-release metoprolol started shortly before surgery reduced myocardial infarction but increased stroke and mortality, associated with hypotension and bradycardia.
Practical application
- Established therapy is generally continued, including on the morning of surgery, with adjustment for the patient’s haemodynamic state and other clinical circumstances.
- Abrupt withdrawal can cause rebound tachycardia and ischaemia.
- Individual parameters for hypotension or bradycardia can help guide postoperative dosing and reassessment.
- If oral administration is interrupted, an intravenous alternative may be appropriate for a specific indication, with dose selection and monitoring by the treating team.
- The original indication, such as rate control or heart-failure treatment, remains relevant when doses are adjusted.
Sources
- 2024 AHA/ACC guideline for perioperative cardiovascular management for non-cardiac surgery
- POISE Study Group: perioperative extended-release metoprolol trial (2008)