Beta Blockade: Protection or Panacea
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1 Beta Blockade: Protection or Panacea Jason Axt
2 Jason s Recommendations Perioperative β Blockade (BB) If on BB stay on If Vascular Sx + documented ischemia - start. 2+ risk factors - start Use in isolated blunt head trauma Use for aortic dissection / trauma Use for postop HTN Use for Atrial Fibrillation
3 Background Risk of Perioperative MI: 1% Risk of Cardiac Death: 0.5% Physiologic Stresses of Surgery Imbalance between myocardial oxygen supply and demand Plaque disruption (50% of MI s) Inflammatory mediators released during operative interventions (SIRS)
4 Theoretic Basis for β-blockade Reduce Myocardial Oxygen Demand Neg Inotrope, Chronotrope, Dromotrope Anti-inflammatory properties Attenuation of renin-angiotensin effects
5 The Beta Receptor B 1 : cardiac chronotrope, inotrope, and lipolysis B 2 : bronchodilation, vasodilation, and uterine relaxation B 3 : lipolysis in adipose tissue
6 The Drugs 1. Non-selective - B 1 + B 2 (CI in Asthma) Propanolol, tomolol, pindolol, nadolol, labetolol (also blocks A 1 ) 2. Selective - B 1 Acebutolol, Betaxolol, Esmolol (short acting), Atenolol, Metoprolol
7 Side Effects Common side effects: Drowsiness or fatigue. Cold hands and feet. Weakness or dizziness. Dry mouth, eyes, and skin. Less common side effects: Wheezing, trouble breathing, or shortness of breath. Slow heartbeat. Trouble sleeping or vivid dreams while asleep. Swelling of the hands and feet. Rare side effects: Abdominal cramps. Throwing up. Diarrhea. Constipation. Back or joint pain. Skin rash. Sore throat.depression. Memory loss, confusion, or hallucinations. Impotence.
8 Surgical Indications Cardiac risk reduction Traumatic brain injury Aortic dissection - traumatic and otherwise Atrial Fibrillation HTN
9 Perioperative Risk Reduction Lot of enthusiasm Some retrospective studies 50-90% reduction of perioperative cardiac death in patients at risk undergoing noncardiac sx Not able to repeat in prospective RCTs
10 POISE Perioperative Ischemic Evaluation Randomized Controlled Trial 8351 Patients with Cardiovascular Risk but not on β Blockers Treatment Patients 100 mg Metoprolol before and after Sx 200 mg daily sustained release after Sx
11 POISE Perioperative Ischemic Evaluation Results: BB vs placebo Cardiac event: HR 0.8 Stroke: HR 2.2 Death: HR 1.3
12 Criticisms POISE Perioperative Ischemic Evaluation Only patients naïve to BB High doses of BB
13 American College of Cardiology Foundation (ACCF) American Heart Association (AHA) 2009 Recommendations Class I: Benefit >>> Risk Should Do Continue BB in patients already receiving for those with class I indications. Class I indications: Unstable coronary syndromes Decompensated HF (NYHF class IV) Significant arrhythmias Severe valvular disease
14 AHA/ ACCF 2009 Recommendations Class II a: Benefit >> Risk reasonable BB titrated to HR and BP are probably recommended in Vascular surgery patients at high cardiac risk due to finding of cardiac ischemia Vascular surgery patients with >1 clinical risk factor Those undergoing intermediate risk surgery with > 1 clinical risk factor.
15 AHA/ ACCF 2009 Recommendations Class II b: Benefit Risk consider Use of BB is uncertain in Vascular surgery patients with 1 clinical risk factor in the absence of CAD. Vascular surgery patients with no risk factors and not currently taking BB.
16 AHA/ ACCF 2009 Recommendations Class III: Risk Benefit Avoid Use of BB is harmful Those with contraindications.
17 AHA/ ACCF 2009 Recommendations Clinical Risk Factors: History of ischemic heart disease Compensated or prior heart failure History of cerebrovascular disease DM Renal insufficiency (scr > 2 mg/dl)
18 A 50 year old woman with goiter develops mental status changes, nausea, and vomiting shortly after undergoing elective breast surgery. On examination, she is extremely anxious, tachycardic, and febrile to 39.5 C. Urgent treatment of her condition should include all the following except A.Beta blockade B.Propylthiouriacil (PTU) C.Antipyretics D.IV dantrolene E.Fluid resuscitation
19 A 50 year old woman with goiter develops mental status changes, nausea, and vomiting shortly after undergoing elective breast surgery. On examination, she is extremely anxious, tachycardic, and febrile to 39.5 C. Urgent treatment of her condition should include all the following except A.Beta blockade B.Propylthiouriacil (PTU) C.Antipyretics D.IV dantrolene E.Fluid resuscitation
20 AHA/ ACCF Surgery Risk Stratification Vascular Aortic, Major, Peripheral Intermediate Intraperitoneal Intrathoracic Head and Neck Orthopedic Prostate Low Endoscopy Breast Cataract Ambulatory
21 Contraindications Hypersensitivity Sinus bradycardia (In MI < 45 BPM) > 1º heart block Cardiogenic shock Overt cardiac failure SBP < 100 mm Hg
22 Bottom Line On BB - do not stop Start BB if receiving Vascular surgery and has evidence of ischemia Intermediate impact or vascular surgery and > 1 risk factor
23 Blunt Head Injury Beta Blockade in isolated head injury causes increased survival There is a catecholamine surge associated with traumatic brain injury Recent study of 1156 patients: Showed BB use to be independent predictor of survival
24 Trauma Unit Protocol BB in all TBI with: Intracranial Hemorrhage by CT & Hyperarenergic state Use Propanolol or Labetolol (lipophilic) Propanolol 10 mg PT/PO q8h No gut access: Labetolol mg IV q4h Start h after resuscitation r/o sepsis and unaddressed pain Continue 14 days
25 DASH after TBI study Decreasing Adrenergic or Sympathetic Hyperactivity After Severe Traumatic Brain Injury Severe (GCS < 8) Traumatic Brain Injury (TBI) 7 day tx and 12 month total observation Propranolol 1 mg IV q 6 hours for 7 days. Clonidine 0.1 mg pt q 12 hours x 7 days.
26 Blood Pressure Useful for post op hypertension Can be given IV for patient with ileus. (only on 9n or units) Easy to titrate. Metoprolol 5 mg IV x 3 (repeat q 4-6 hrs) mg PO BID (max 400 mg / day)
27 Arrhythmia Atrial fibrillation Trial of Metoprolol 5 mg IV x 3 to control rapid atrial fibrillation. Sometimes will convert new onset afib.
28 Aortic Dissection Medical treatment - minimize change in pressure over time Control BP Usual Goal SBP <110 Nitroprusside Control HR - Goal HR = 60 Esmolol or Labetolol Transtion to Metoprolol or Propanolol PO
29 Jason s Recommendations Perioperative β Blockade If on BB Stay on If Vascular Sx + documented ischemia - start. 2+ Risk Factors - start Use in isolated blunt head trauma Use for aortic dissection / trauma Use for postop HTN Use for Atrial Fib
30 According to AHA guidelines Should You Start BB on 25 y/o with crohns undergoing exlap for stricture?
31 According to AHA guidelines Should You Start BB on 25 y/o with crohns undergoing exlap for stricture? Not recommended (Class III) Intermediate risk surgery Doesn t have >1 risk factor
32 According to AHA guidelines Should You Start BB on 66 y/o with DM getting Fem-Pop bypass?
33 According to AHA guidelines Should You Start BB on 66 y/o with DM getting Fem-Pop bypass? Reasonable (Class IIa) Vascular surgery 1 risk factor: DM
34 AHA/ ACCF 2009 Recommendations Class II a: Benefit >> Risk reasonable BB titrated to HR and BP are probably recommended in Vascular surgery patients at high cardiac risk due to finding of cardiac ischemia Vascular surgery patients with >1 clinical risk factor Those undergoing intermediate risk surgery with > 1 clinical risk factor.
35 AHA/ ACCF Surgery Risk Stratification Vascular Aortic, Major, Peripheral Intermediate Intraperitoneal Intrathoracic Head and Neck Orthopedic Prostate Low Endoscopy Breast Cataract Ambulatory
36 According to AHA guidelines Should You Start BB on Otherwise healthy 50 y/o with newly discovered high grade aortic disease undergoing AVR?
37 According to AHA guidelines Should You Start BB on Otherwise healthy 50 y/o with newly discovered high grade aortic disease undergoing AVR? Yes (Class I)
38 American College of Cardiology Foundation (ACCF) American Heart Association (AHA) 2009 Recommendations Class I: Benefit >>> Risk Should Do Continue BB in patients already receiving for those with class I indications. Class I indications: Unstable coronary syndromes Decompensated HF (NYHF class IV) Significant arrhythmias Severe valvular disease
39 According to AHA guidelines Should You Start BB on Otherwise healthy 35y/o getting repair of femoral AVM?
40 According to AHA guidelines Should You Start BB on Otherwise healthy 35y/o getting repair of femoral AVM? Consider Class IIb Vascular Surgery No additional risk factors
41 AHA/ ACCF 2009 Recommendations Class II b: Benefit Risk consider Use of BB is uncertain in Vascular surgery patients with 1 clinical risk factor in the absence of CAD. Vascular surgery patients with no risk factors and not currently taking BB.
42 AHA/ ACCF 2009 Recommendations Clinical Risk Factors: History of ischemic heart disease Compensated or prior heart failure History of cerebrovascular disease DM Renal insufficiency (scr > 2 mg/dl)
43 Questions
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