Beta Blockers to Prevent Perioperative MI

OVERVIEW

  • The use of Beta-blockers in perioperative medicine has been an issue of intense research in Anaesthesia.
  • Patients that are believed to benefit from beta-blockers are those with risk factors for ischaemic heart disease (HT, DM, hypercholesterolaemia, previous MI, angina, controlled heart failure)
  • There are arguments for and against their use.

Benefits

  • lowering of heart rate
  • decreased Q
  • decreased afterload
  • decreased myocardial oxygen consumption
  • prevention of perioperative tachycardia and subsequent non-ST elevation myocardial infarction
  • prevention of arrhythmia (atrial fibrillation)
  • decrease in bleeding

Disadvantages

  • a significant increase in episodes of perioperative hypotension
  • sympathetic blockade decreasing response to hypovolaemia (tachycardia and increase in cardiac output)
  • a significant increase in perioperative cerebrovascular events
  • increased risk of bradycardia
  • a significant increase morbidity and mortality

-> a number of these adverse effects have been documented via a recent trial entitled the POISE trial

An approach:

  • if a patient is already taking beta-blockers for an established medical problem then I continue throughout the perioperative period
  • I do not start my patients on beta-blockers perioperatively based on information obtained from the POISE trial
  • if a patient is seen preoperatively and may benefit from beta blockade, has at least 1 week prior to their surgery I would consider starting an agent if there were no contraindications (as per DECREASE trial protocol)

References and Links

  • Graber MA, Dachs RJ, Darby-Stewart A. Beta blockers and noncardiac surgery: why the POISE study alone should not change your practice.Am Fam Physician. 2010 Mar 15;81(6):717. PMID: 20229970 [Fulltext]
  • POISE Study Group, Devereaux PJ, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008 May 31;371(9627):1839-47. Epub 2008 May 12. PMID: 18479744
  • Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med. 1999;341(24):1789–1794. PMID: 10588963 [Fulltext]

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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