Perioperative Beta Blocker Therapy

Background and Rationale

• Maingot's Abdominal Operations notes that catecholamine surges "can alter the tensile strength of coronary plaques and incite plaque rupture... contributing to platelet aggregation and thrombosis after plaque rupture."

Historical Arc: From Enthusiasm to Caution

• A 1998 landmark trial (Mangano et al.) showed a 55% reduction in mortality in non-cardiac surgical patients with known coronary disease given atenolol perioperatively.
• The DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography) studies appeared to confirm a 10-fold reduction in perioperative MI and death.
• Beta blockade was widely adopted as a quality measure and incorporated into the Surgical Care Improvement Project (SCIP).

• Reduced perioperative MI
• BUT at the cost of more bradycardic and hypotensive episodes, more strokes, and - critically - higher overall mortality

• Harrison's 22E (2025) states: "Research misconduct has discredited the DECREASE family of studies, which previously contributed to the bedrock of data supporting the use of perioperative beta blockade but have now been retracted."

Current Evidence Summary

Current ACC/AHA Guideline Recommendations

• Abrupt withdrawal causes rebound tachycardia and hypertension, increasing ischemic risk.
• Class I recommendation: continue chronic beta blocker therapy throughout the perioperative period.

• Class III (Harm): Starting on the day of surgery is associated with increased stroke, hypotension, and death (as seen in POISE).
• Avoidance of abrupt initiation is a firm recommendation.

• Reasonable to consider (Class IIb, Level of Evidence B) in patients with:
  • Intermediate- or high-risk ischemia on preoperative stress testing
  • Three or more RCRI (Revised Cardiac Risk Index) risk factors
• If initiated, therapy should begin at least 7-10 days (ideally 28 days) before surgery to allow dose titration and assessment of safety and tolerability.
• Fuster and Hurst's The Heart (15th ed.) recommends initiation "ideally at least 28 days prior to surgery to avoid adverse events."

Practical Prescribing Considerations

• RCRI score ≥ 3
• Known ischemia on preoperative testing
• High-risk vascular procedures (though even here evidence is equivocal)
• Transplant candidates with history of CAD (evidence supports reduction in CAD events)

• Low-risk patients undergoing low- or intermediate-risk surgery
• Any patient where initiation would begin on the day of surgery

• An epidemiological analysis of ~40,000 high-risk patients found lower 30-day and 1-year mortality with atenolol compared to metoprolol.
• Retrospective data suggest preoperative and intraoperative metoprolol may be associated with increased stroke risk vs. atenolol or esmolol.

• Beta blockers should not be the initial treatment for tachycardia caused by hypovolemia, anemia, pain, or infection. These require treatment of the underlying cause.

Dosing Approach for New Initiation

• Start with a small dose and titrate to heart rate effect.
• Titrate over 7-10 days (minimum) to 28 days (preferred) before elective surgery.
• Target heart rate: generally 60-80 bpm.
• Avoid large-dose acute initiation - this was a major flaw of the POISE protocol.

Key Risks to Monitor

Summary: The Current Paradigm

• Continue what patients are already taking (strong evidence of harm from withdrawal).
• Never start on the day of surgery.
• Consider initiation only in genuinely high-risk patients, started well in advance with careful titration.
• For most low- to intermediate-risk patients undergoing noncardiac surgery, newly starting a beta blocker in the perioperative period does not improve outcomes and may cause harm.

Sources: Harrison's Principles of Internal Medicine 22E (2025) | Miller's Anesthesia, 10e | Barash Clinical Anesthesia, 9e | Fuster and Hurst's The Heart, 15th ed. | Maingot's Abdominal Operations