Perioperative β-blockers: Difference between revisions
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{{CMG}}, [[User:Johnfanisrour|Johnfanisrour]] | |||
==Overview== | ==Overview== | ||
Earlier [[perioperative]] trials of [[β-blockers]] involved small numbers of patients undergoing a wide range of surgical procedures. In addition, different β-blockers were used without titration to a desired effect (target heart rate). This high degree of heterogeneity resulted in variable opinion regarding the use of β-blockers in the perioperative phase. Published meta-analyses included these small and relatively heterogeonus trials and resulted in similar variable conclusions. Timing, location, and route of administration also complicate the | Earlier [[perioperative]] trials of [[β-blockers]] involved small numbers of patients undergoing a wide range of surgical procedures. In addition, different β-blockers were used without titration to a desired effect (target heart rate). This high degree of heterogeneity resulted in variable opinion regarding the use of β-blockers in the perioperative phase. Published meta-analyses included these small and relatively heterogeonus trials and resulted in similar variable conclusions. Timing, location, and route of administration also complicate the decision regarding the use of β-blockers peri-operatively. | ||
==Areas of agreement== | ==Areas of agreement== | ||
β-blockers should be continued in patients undergoing surgery who are already receiving β-blockers for any ACC/AHA class 1 recommendation. Interruption of therapy in these patients may lead to recurrent angina, | β-blockers should be continued in patients undergoing surgery who are already receiving β-blockers for any ACC/AHA class 1 recommendation. Interruption of therapy in these patients may lead to recurrent angina, [[arrhythmia]]s, [[rebound hypertension]], or other cardiovascular (CV) complications that may increase perioperative morbidity and mortality. | ||
The use of β-blockers is considered class 1 and class IIa in patients undergoing high risk vascular surgery with known [[coronary heart disease]] or have one or more clinical cardiovascular (CV) risk factors, respectively (Level of evidence= B, LOE B). This includes patients who were found to have myocardial ischemia on preoperative testing. | The use of β-blockers is considered class 1 and class IIa in patients undergoing high risk vascular surgery with known [[coronary heart disease]] or have one or more clinical cardiovascular (CV) risk factors, respectively (Level of evidence= B, LOE B). This includes patients who were found to have [[myocardial ischemia]] on preoperative testing. | ||
==Weak evidence== | ==Weak evidence== | ||
The weakest evidence for the use of perioperative β-blockers is for patients undergoing intermediate-risk surgery who have at least one clinical risk factor and for patients undergoing vascular surgery who have no clinical risk factors. | The weakest evidence for the use of perioperative β-blockers is for patients undergoing intermediate-risk surgery who have at least one clinical risk factor and for patients undergoing vascular surgery who have no clinical risk factors. | ||
==Potential hazards== | ==Potential hazards== | ||
This was underscored by the [[POISE]] trial (Perioperative Ischemic Evaluation). This multicenter, randomized, placebo-controlled trial included 8351 patients who underwent intermediate or high risk surgery. Patients were randomized to receive either placebo or a fixed dose of 100 mg of [[metoprolol]], which was administered 2 to 4 hours before surgery and again within 6 hours after surgery. A maintenance dosage of 200 mg/day of the drug was administered postoperatively for 30 days. Patients were continued on this dosage as long as their heart rate remained at least 50 beats/min and their systolic blood pressure exceeded 100 mm Hg. | This was underscored by the [[POISE]] trial (Perioperative Ischemic Evaluation). This multicenter, randomized, placebo-controlled trial included 8351 patients who underwent intermediate or high risk surgery. Patients were randomized to receive either placebo or a fixed dose of 100 mg of [[metoprolol]], which was administered 2 to 4 hours before surgery and again within 6 hours after surgery. A maintenance dosage of 200 mg/day of the drug was administered postoperatively for 30 days. Patients were continued on this dosage as long as their heart rate remained at least 50 beats/min and their [[systolic blood pressure]] exceeded 100 mm Hg. | ||
Despite the significant reduction in the primary composite end points (cardiovascular death, [[cardiac arrest]], and nonfatal [[myocardial infarction]]) with metoprolol therapy vs placebo (5.8% vs 6.9%, respectively; hazard ratio [HR], 0.84; P=.04), the total 30-day mortality rate was greater in the metoprolol-treated patients than in the placebo group (3.1% vs 2.3%, respectively; HR, 1.33; P=.03), as was the incidence of clinically important hypotension (15% vs 9.7%; HR, 1.55; P<.001), severe [[bradycardia]] (6.6% vs 2.4%; HR, 2.74; P<.001), and stroke (1.0% vs 0.5%; HR, 2.17; P=.005). | Despite the significant reduction in the primary composite end points (cardiovascular death, [[cardiac arrest]], and nonfatal [[myocardial infarction]]) with metoprolol therapy vs placebo (5.8% vs 6.9%, respectively; hazard ratio [HR], 0.84; P=.04), the total 30-day mortality rate was greater in the metoprolol-treated patients than in the placebo group (3.1% vs 2.3%, respectively; HR, 1.33; P=.03), as was the incidence of clinically important hypotension (15% vs 9.7%; HR, 1.55; P<.001), severe [[bradycardia]] (6.6% vs 2.4%; HR, 2.74; P<.001), and stroke (1.0% vs 0.5%; HR, 2.17; P=.005). | ||
[[Stroke]], [[hypotension]], and bradycardia were all predictors of increased mortality. | [[Stroke]], [[hypotension]], and bradycardia were all predictors of increased mortality. | ||
==Barriers to the effective use of perioperative β-blockers== | ==Barriers to the effective use of perioperative β-blockers== | ||
*The titration of β-blockers dosage to achieve target resting heart rate of less 65 beats/min can pose logestical problems. | *The titration of β-blockers dosage to achieve target resting heart rate of less 65 beats/min can pose logestical problems. | ||
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** Titration of β-blockers dosage can results in hypotension, bradycardia, and other side effects. | ** Titration of β-blockers dosage can results in hypotension, bradycardia, and other side effects. | ||
** The variable metabolic effects produced by β-blockers during their first pass through the hepatic venous circulation after absorption result in variable serum levels (and clinical effects) depending on the individual patient. | ** The variable metabolic effects produced by β-blockers during their first pass through the hepatic venous circulation after absorption result in variable serum levels (and clinical effects) depending on the individual patient. | ||
==Recommendations== | ==Recommendations== | ||
* The use of perioperative β-blockers should be limited to class 1 or class IIa recommendations (see above). | * The use of perioperative β-blockers should be limited to class 1 or class IIa recommendations (see above). | ||
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==Guidelines== | ==Guidelines== | ||
=== 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade : Focused Update on Perioperative Beta-Blocker Therapy<ref>http://circ.ahajournals.org/content/120/21/2123.full.pdf</ref>=== | === 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade : Focused Update on Perioperative Beta-Blocker Therapy<ref>http://circ.ahajournals.org/content/120/21/2123.full.pdf</ref> (DO NOT EDIT)=== | ||
These guidelines are update of the 2007 Guidelines.<ref>http://circ.ahajournals.org/content/113/22/2662.full</ref> | These guidelines are update of the 2007 Guidelines.<ref>http://circ.ahajournals.org/content/113/22/2662.full</ref> | ||
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|- | |- | ||
|bgcolor="LightCoral"|<nowiki>''</nowiki>'''2.''' Routine administration of high-dose beta blockers in the absence of dose titration is not useful and may be harmful to patients not currently taking beta blockers who are undergoing noncardiac surgery.([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>''</nowiki> (New Recommendation) | |bgcolor="LightCoral"|<nowiki>''</nowiki>'''2.''' Routine administration of high-dose beta blockers in the absence of dose titration is not useful and may be harmful to patients not currently taking beta blockers who are undergoing noncardiac surgery. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>''</nowiki> (New Recommendation) | ||
|} | |} | ||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>''</nowiki>'''1.''' Beta blockers titrated to heart rate and blood pressure are probably recommended for patients undergoing vascular surgery who are at high cardiac risk owing to coronary artery disease or the finding of cardiac ischemia on preoperative testing. | |bgcolor="LemonChiffon"|<nowiki>''</nowiki>'''1.''' Beta blockers titrated to heart rate and blood pressure are probably recommended for patients undergoing vascular surgery who are at high cardiac risk owing to coronary artery disease or the finding of cardiac ischemia on preoperative testing.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]])''<nowiki>''</nowiki> (Revised recommendation) | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>''</nowiki>'''2.''' Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the presence of more than 1 clinical risk factor ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]])<nowiki>''</nowiki> (Revised recommendation with level of class changed from B to C) | |bgcolor="LemonChiffon"|<nowiki>''</nowiki>'''2.''' Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the presence of more than 1 clinical risk factor ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]])''<nowiki>''</nowiki> (Revised recommendation with level of class changed from B to C) | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>''</nowiki>'''3.'''Beta blockers are | |bgcolor="LemonChiffon"|<nowiki>''</nowiki>'''3.''' Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom preoperative assessment identifies coronary artery disease or high cardiac risk, as defined by the presence of more than 1 clinical risk factor,* who are undergoing intermediate-risk surgery. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]])''<nowiki>''</nowiki> | ||
|} | |} | ||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>''</nowiki>'''1.''' | |bgcolor="LemonChiffon"|<nowiki>''</nowiki>'''1.''' The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate risk procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor in the absence of coronary artery disease.* ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]])''<nowiki>''</nowiki> | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>''</nowiki>'''2.''' | |bgcolor="LemonChiffon"|<nowiki>''</nowiki>'''2.''' The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors* who are not currently taking beta blockers. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]])''<nowiki>''</nowiki> | ||
|} | |} | ||
<nowiki>*</nowiki>Clinical risk factors include history of ischemic heart disease, history of compensated or prior heart failure, history of cerebrovascular disease, diabetes mellitus, | |||
and renal insufficiency (defined in the Revised Cardiac Risk Index as a preoperative serum creatinine of >2 mg/dL). | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
Latest revision as of 15:25, 31 October 2012
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Johnfanisrour
Overview
Earlier perioperative trials of β-blockers involved small numbers of patients undergoing a wide range of surgical procedures. In addition, different β-blockers were used without titration to a desired effect (target heart rate). This high degree of heterogeneity resulted in variable opinion regarding the use of β-blockers in the perioperative phase. Published meta-analyses included these small and relatively heterogeonus trials and resulted in similar variable conclusions. Timing, location, and route of administration also complicate the decision regarding the use of β-blockers peri-operatively.
Areas of agreement
β-blockers should be continued in patients undergoing surgery who are already receiving β-blockers for any ACC/AHA class 1 recommendation. Interruption of therapy in these patients may lead to recurrent angina, arrhythmias, rebound hypertension, or other cardiovascular (CV) complications that may increase perioperative morbidity and mortality. The use of β-blockers is considered class 1 and class IIa in patients undergoing high risk vascular surgery with known coronary heart disease or have one or more clinical cardiovascular (CV) risk factors, respectively (Level of evidence= B, LOE B). This includes patients who were found to have myocardial ischemia on preoperative testing.
Weak evidence
The weakest evidence for the use of perioperative β-blockers is for patients undergoing intermediate-risk surgery who have at least one clinical risk factor and for patients undergoing vascular surgery who have no clinical risk factors.
Potential hazards
This was underscored by the POISE trial (Perioperative Ischemic Evaluation). This multicenter, randomized, placebo-controlled trial included 8351 patients who underwent intermediate or high risk surgery. Patients were randomized to receive either placebo or a fixed dose of 100 mg of metoprolol, which was administered 2 to 4 hours before surgery and again within 6 hours after surgery. A maintenance dosage of 200 mg/day of the drug was administered postoperatively for 30 days. Patients were continued on this dosage as long as their heart rate remained at least 50 beats/min and their systolic blood pressure exceeded 100 mm Hg. Despite the significant reduction in the primary composite end points (cardiovascular death, cardiac arrest, and nonfatal myocardial infarction) with metoprolol therapy vs placebo (5.8% vs 6.9%, respectively; hazard ratio [HR], 0.84; P=.04), the total 30-day mortality rate was greater in the metoprolol-treated patients than in the placebo group (3.1% vs 2.3%, respectively; HR, 1.33; P=.03), as was the incidence of clinically important hypotension (15% vs 9.7%; HR, 1.55; P<.001), severe bradycardia (6.6% vs 2.4%; HR, 2.74; P<.001), and stroke (1.0% vs 0.5%; HR, 2.17; P=.005). Stroke, hypotension, and bradycardia were all predictors of increased mortality.
Barriers to the effective use of perioperative β-blockers
- The titration of β-blockers dosage to achieve target resting heart rate of less 65 beats/min can pose logestical problems.
- Many patients present to the preoperative medical clinic just one or few days prior to their scheduled procedure.
- Titration of β-blockers dosage can results in hypotension, bradycardia, and other side effects.
- The variable metabolic effects produced by β-blockers during their first pass through the hepatic venous circulation after absorption result in variable serum levels (and clinical effects) depending on the individual patient.
Recommendations
- The use of perioperative β-blockers should be limited to class 1 or class IIa recommendations (see above).
- Patients should be seen earlier during the preoperative period for carefull titration of β-blockers.
- Clinicians should pay attention in regards to the use of concurrent medications that result in bradycardia and/or hypotension.
Guidelines
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade : Focused Update on Perioperative Beta-Blocker Therapy[1] (DO NOT EDIT)
These guidelines are update of the 2007 Guidelines.[2]
| Class I |
| ''1. Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers for treatment of conditions with ACCF/AHA Class I guideline indications for the drugs. (Level of Evidence: C)'' |
| Class III (No Benefit) |
| ''1. Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta blockade (Level of Evidence: C)'' |
| ''2. Routine administration of high-dose beta blockers in the absence of dose titration is not useful and may be harmful to patients not currently taking beta blockers who are undergoing noncardiac surgery. (Level of Evidence: B)'' (New Recommendation) |
| Class IIa |
| ''1. Beta blockers titrated to heart rate and blood pressure are probably recommended for patients undergoing vascular surgery who are at high cardiac risk owing to coronary artery disease or the finding of cardiac ischemia on preoperative testing.(Level of Evidence:B)'' (Revised recommendation) |
| ''2. Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the presence of more than 1 clinical risk factor (Level of Evidence:C)'' (Revised recommendation with level of class changed from B to C) |
| ''3. Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom preoperative assessment identifies coronary artery disease or high cardiac risk, as defined by the presence of more than 1 clinical risk factor,* who are undergoing intermediate-risk surgery. (Level of Evidence:B)'' |
| Class IIb |
| ''1. The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate risk procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor in the absence of coronary artery disease.* (Level of Evidence:C)'' |
| ''2. The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors* who are not currently taking beta blockers. (Level of Evidence:C)'' |
*Clinical risk factors include history of ischemic heart disease, history of compensated or prior heart failure, history of cerebrovascular disease, diabetes mellitus, and renal insufficiency (defined in the Revised Cardiac Risk Index as a preoperative serum creatinine of >2 mg/dL).