Perioperative Beta-Blocker Use for Noncardiac Surgery
Perioperative beta-blockers should be continued in patients already receiving chronic therapy. [1]
Routine prophylactic initiation of beta-blockers in beta-blocker–naïve patients is not recommended due to harm shown in perioperative trials. 2022 ESC Noncardiac Surgery Guideline Slide Set
Medication Selection Algorithm
Beta-blocker continuation
- Continue beta-blockers perioperatively without dose adjustment in patients already taking them. [1]
- Continue beta-blockers in the perioperative period in patients on chronic therapy. [2]
Beta-blocker initiation (only when a new indication exists)
- Initiate beta-blockers when a new clinical indication exists and start far enough before surgery to allow tolerability assessment and dose titration. [1]
- The initiation interval preferred in the 2024 AHA/ACC perioperative guideline is optimally more than 7 days before surgery. [1]
Beta-blocker agents (practical selection)
- Common perioperative choices include metoprolol, atenolol, bisoprolol, carvedilol, and similar agents used for chronic cardiovascular indications. [1]
- Treatment should be titrated to hemodynamic tolerability rather than using a single fixed prophylactic high-dose strategy. [2]
Key Evidence Supporting This Recommendation
POISE-1 (metoprolol strategy started shortly before surgery)
- In POISE-1, perioperative extended-release metoprolol was associated with higher all-cause mortality (3.1% vs 2.3%) and higher stroke (1.0% vs 0.5%) compared with placebo, despite reduction in myocardial infarction. [3]
- POISE used metoprolol started 2–4 hours pre-induction and continued for about 1 month postoperatively. [3]
Observational signal for perioperative stroke risk when started perioperatively
- Perioperative metoprolol exposure has been associated with markedly increased perioperative stroke risk in published analyses. [4]
Monotherapy Versus Combination Therapy
- Beta-blockers are generally used as part of perioperative cardiovascular medical therapy when a chronic indication exists. [1]
- Combination with other cardioprotective agents is consistent with guideline-directed medical therapy for underlying conditions such as ischemic heart disease and heart failure, rather than as a strategy to permit prophylactic beta-blocker initiation. [1]
Initiation Thresholds and Indications
Beta-blocker continuation indication
- Chronic beta-blocker therapy is an indication for perioperative continuation. [1]
Beta-blocker initiation indication
- Beta-blockers should be initiated only when a new indication is present rather than prophylactically for all patients undergoing noncardiac surgery. [1]
- If beta-blockers are newly indicated, initiation should occur far enough before surgery to assess tolerability and allow dose titration, optimally more than 7 days before surgery. [1]
Day-of-surgery initiation
- Starting beta-blockers on the day of surgery is not recommended. [1]
Common Pitfalls to Avoid
- Routine prophylactic initiation of beta-blockers in beta-blocker–naïve patients is not recommended. 2022 ESC Noncardiac Surgery Guideline Slide Set
- Perioperative beta-blocker initiation at short notice (including on the day of surgery) is associated with higher risk signals and should be avoided. [1]
- High-dose non-titrated strategies that begin immediately preoperatively should be avoided. [3]
Target Hemodynamic Goals During Titration
- Beta-blocker titration should be guided by heart rate and blood pressure tolerability rather than fixed prophylactic dosing. [2]
Postoperative Continuation
- Beta-blockers should be continued through the perioperative period in patients already receiving chronic therapy. [2]
- Perioperative beta-blocker decisions should remain aligned with the patient’s underlying cardiovascular indication rather than new perioperative prophylaxis. [1]