Perioperative use of beta-blocker in noncardiac surgery: a multicenter educational intervention to achieve best practice guidelines

[Perioperative pharmacological myocardial protection. Systematic literature-based process optimization]

Patients with major cardiac risk factors have been suggested to benefit from perioperative beta-blockade. However, the scientific literature on perioperative beta-blockade needs to be interpreted carefully. So far treatment recommendations for millions of patients are based on heterogeneous data from randomized trials with divergent study results. The evidence for a beneficial effect of perioperative beta-blockers is sufficient only for a limited subpopulation of high cardiac risk patients undergoing vascular surgery. Perioperative beta-blocker treatment is not useful in patients with intermediate risk and may even be harmful in patients with low cardiac risk. Therefore, an individualized risk-benefit analysis is an important prerequisite for a rational therapy that may be based on a standardized protocol including the Revised Cardiac Risk Index. Such a protocol is presented in this article. A recently reported trial (POISE) demonstrated that perioperative treatment with high doses of oral metoprolol efficiently reduces the incidence of cardiovascular events. However, due to severe adverse effects (hypotension, bradycardia, stroke) the total mortality was increased. Thus, dose adjustments, safety aspects, and monitoring of beta-blocker therapy seem to be mandatory. So far evidence from relevant trials about how to best implement perioperative beta-blockade is lacking. This article offers a simple clinical concept for this purpose.

The use of beta-blockers to decrease adverse perioperative cardiac events

As the population ages, more surgeries are performed on patients with increased risk factors. Many of these surgeries will result in complications and mortality. Myocardial ischemia is often associated with cardiac complications in the perioperative patient. Unfortunately, an episode of myocardial ischemia will result in a 70% mortality rate. Perioperative patients are complex because of their atypical presentation, incisional pain, and the effects of analgesia. The critical care nurse must be able to determine a patient's risk factors and surgical risks and then take measures to ensure that the patient receives adequate treatment both before and after surgery. beta-Blockers may decrease a patient's risk of developing myocardial ischemia, yet they are often underused. A multidisciplinary approach is needed to ensure the proper use of beta-blockers in an effort to reduce cardiac complications in the perioperative elderly patient.