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ACC – Amanda Jekowsky: (202) 375-6645,
ajekowsk@acc.org
November
2, 2009
ACC/AHA Release Revised Guidelines for the Prophylactic Use
of Beta Blockers to Minimize Cardiac Risk Around Time of (Noncardiac)
Surgery
Beta blocker therapy should be considered within
context of patients’ clinical and surgical risk
Cardiac complications around the time of noncardiac surgery
are relatively common and can be serious. The American College
of Cardiology (ACC) and the American Heart Association (AHA)
today release a Focused Update to the Practice Guidelines
based on new clinical trial data that summarizes and sheds
light on the risks and benefits of using beta blockers to
reduce cardiac events during noncardiac surgeries, and provides
specific recommendations about which patients will likely
benefit and in which patients there is not enough evidence
to recommend their use.
“Any surgery, particularly a high-risk procedure, is
a stress on the heart, especially for those with underlying
circulation problems or other cardiovascular risk factors,”
says Kirsten E. Fleischmann, M.D., M.P.H., chair of the 2009
writing group that reviewed the latest evidence on the perioperative
use of beta blockers. “In general, the higher the risk
from a cardiovascular standpoint, the more likely a patient
will benefit from beta blockers. However, newer data from
the POISE [Perioperative Ischemic Evaluation] trial suggest
that starting higher doses of beta blockers acutely on the
day of surgery is associated with risk as well, so careful
patient selection, dose adjustment and monitoring throughout
the perioperative period is key.”
More than 30 million noncardiac surgeries are performed in
the United States each year. Cardiac problems around the time
of surgery are a major cause of complications and death in
these patients, prolonging hospitalizations and increasing
costs. Beta blockers are designed to help protect against
heart attack around the time of surgery by lowering heart
rate and helping to block the effects of stress hormones on
the heart.
The recommendation to continue beta blockers perioperatively
in those patients who are already receiving them remains current
since the initial 2007 guidelines were published. The workgroup
advises beta blockers are reasonable to consider in:
- Patients at high risk for heart attacks or other cardiac
complications because of abnormal stress test results or
known coronary artery disease who undergo vascular surgery
- High risk patients undergoing intermediate risk surgery
or in those with multiple risk factors for complications
(e.g., diabetes, a history of heart failure, significant
kidney disease) who undergo vascular surgery
However, authors caution that when beta blockers are started
in patients not yet taking them, the medication should be
initiated well before the procedure and titrated up as blood
pressure and heart rate allow.
“We recommend beta blockers be started well in advance
of surgery and not at higher doses right off the bat,”
says Dr. Fleischmann. “These updated guidelines are
intended to provide guidance for the appropriate use of beta
blockers to help reduce the risk of cardiac complications.
Physicians must be vigilant in assessing patients’ cardiac
risk and weighing this against potential side effects of the
therapy.”
According to the authors, the usefulness of beta blockers
remains uncertain in lower-risk patients or in those undergoing
lower-risk surgeries (e.g., percutaneous or endovascular procedures),
and requires careful consideration of the risks and benefits.
The guidelines do not advocate for routine administration
of beta blockers, particularly in higher fixed-dose regimens,
begun on the day of surgery based on data from the POISE study.
While there was a reduction in perioperative myocardial infarction
and primary cardiac events among study participants, the use
of beta blockers was also associated with higher rates of
stroke and overall mortality. Beta blockers should not be
used when contraindications exist.
This ACCF/AHA update was developed in collaboration with
the American Society of Echocardiography, American Society
of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular
Anesthesiologists, Society for Cardiovascular Angiography
and Interventions, Society for Vascular Medicine, and Society
for Vascular Surgery.
Full text of the Focused Update will be published in the
November 24, 2009, issue of the Journal of the American
College of Cardiology and the November 24, 2009, Circulation,
and will be posted on the ACC (www.acc.org)
and AHA (www.americanheart.org)
Web sites.
Dr. Fleischmann reports no conflicts of interest.
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About the ACC:
The American College of Cardiology is leading the way to optimal
cardiovascular care and disease prevention. The College is
a 37,000-member nonprofit medical society and bestows the
credential Fellow of the American College of Cardiology upon
physicians who meet its stringent qualifications. The College
is a leader in the formulation of health policy, standards
and guidelines, and is a staunch supporter of cardiovascular
research. The ACC provides professional education and operates
national registries for the measurement and improvement of
quality care. More information about the association is available
online at www.acc.org .
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