Perioperative Beta-Blocker Use for Noncardiac Surgery
Perioperative beta-blocker management is recommended to prioritize continuation in patients already receiving stable beta-blockade and to avoid immediate perioperative initiation in beta-blocker–naïve patients [1].
For beta-blocker–naïve patients, beta-blockers should be initiated only for a new accepted clinical indication, with titration prior to surgery when time allows [1].
Medication Selection Algorithm
Stable chronic beta-blockade is managed with continuation through the perioperative period as appropriate to clinical circumstances [1].
Beta-blockers for perioperative use are selected based on the indication and required titration rather than surgical type [1].
Common oral agents used in perioperative practice include:
- Metoprolol (for example, metoprolol succinate or tartrate) [2]
- Bisoprolol (for example, bisoprolol) [2]
Key Evidence Supporting This Recommendation
Perioperative beta-blockade was associated with fewer myocardial infarctions but increased stroke and all-cause mortality in a landmark large randomized trial when beta-blockade was started immediately prior to surgery [3].
At 1 year, excess adverse outcomes persisted in the same general direction after perioperative beta-blocker use [4].
These risks drove modern guideline emphasis on continuation of stable therapy and avoidance of day-of-surgery initiation in beta-blocker–naïve patients [1].
Monotherapy vs Combination Therapy
Beta-blockers are used as part of broader perioperative cardiovascular medical therapy rather than as isolated “cardiac prophylaxis.”
Continuation of guideline-directed cardiovascular medications is emphasized when they are already indicated, including beta-blockers in patients receiving stable dosing [1].
Important Clarifications and Nuances
Beta-blockers should not be initiated on the day of surgery in beta-blocker–naïve patients due to increased risk observed with perioperative start strategies [1].
In patients scheduled for elective noncardiac surgery with a new accepted indication for beta-blocker therapy, initiation may be performed sufficiently in advance to permit tolerability assessment and titration [1].
Treatment Initiation Thresholds
If already on stable beta-blockers for an accepted indication, beta-blockers should be continued perioperatively as appropriate [1].
For elective surgery when a new indication arises, beta-blockers may be initiated optimally >7 days before surgery to allow titration and tolerability assessment [1].
Beta-blockers should be avoided for initiation on the day of surgery in patients without a preexisting beta-blocker indication [1].
Common Pitfalls to Avoid
Perioperative “routine prophylactic” initiation immediately before surgery is a key pitfall associated with harm in large randomized evidence [2].
Day-of-surgery initiation in beta-blocker–naïve patients is specifically discouraged in contemporary guidance [1].
Target Goals of Therapy
Heart rate and tolerance goals are used for beta-blocker titration when initiation is needed prior to surgery, rather than fixed prophylactic perioperative dosing [1].
Continuation of stable dosing through surgery is preferred over perioperative re-titration when already tolerated [1].