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Perioperative Beta-Blocker Therapy for Noncardiac Surgery

A focused guideline update from the American College of Cardiology and American Heart Association

Sponsoring Organizations: American Heart Association, American College of Cardiology

Purpose: In noncardiac surgery, perioperative beta-blocker therapy has been identified recently as an important quality measure of evidence-based care. Given this development, the ACC and AHA expedited revision of the beta-blocker section of their 2002 guidelines on perioperative evaluation for noncardiac surgery (Journal Watch Cardiology Mar 22 2002).

Key Points:
1. The guidelines now give a class I (top-level) recommendation for continuing beta-blockers in noncardiac-surgery patients who are currently taking them for any ACC/AHA class I indication (e.g., heart failure), rather than just for angina, symptomatic arrhythmias, or hypertension. There remains a class I indication for beta-blockers in patients undergoing vascular surgery whose preoperative testing documents ischemia.

2. In a class IIa recommendation (conflicting evidence, weighted in favor of efficacy), the guideline authors write that perioperative beta-blockers are now "probably recommended" when preoperative assessment identifies high cardiac risk, due to coronary heart disease or multiple clinical risk factors.

3. In a class IIb recommendation (conflicting evidence, with efficacy less well-established), the authors write that perioperative beta-blockers "may be considered" in patients undergoing intermediate- or high-risk procedures who have a single risk factor and also in vascular surgery patients who have low cardiac risk.

4. The recommendation against using beta-blockers in patients with absolute contraindications still stands (class III).

Comment: The new class II indications for perioperative beta-blockade in noncardiac surgery reflect growing evidence of the benefits of beta-blockers in patients with coronary heart disease or risk factors for it, especially when undergoing vascular surgery. Given that class I and III indications have changed little, a major impact on quality measures is unlikely. The authors note many limitations of the existing data and highlight unanswered questions (e.g., about dosing, timing of initiation, and long- vs. short-acting beta-blockers). Still, this focused update is useful in integrating what we have learned since 2002 into our guidelines for best practice.

— Hugh Calkins, MD

Dr. Calkins served on the guideline committee.

Published in Journal Watch Cardiology May 18, 2006

Citation(s):

Fleisher LA et al. ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: Focused update on perioperative beta-blocker therapy. American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). http://www.acc.org/clinical/guidelines/perio/periobetablocker.pdf