1.      There is good evidence that beta-blockers reduce cardiac morbidity and mortality when used in the perioperative period in selected patients.

2.      Who should get beta-blockers?

• Does the patient meet two (2) or more of the following criteria? age > 65, hypertension, current smoker, total cholesterol > 240 mg/dl, or diabetes not requiring insulin.  If yes, give perioperative beta-blocker unless contraindicated.
• Does the patient meet any one (1) of the following criteria? high risk surgical procedure (intraperitoneal, intrathoracic, suprainguinal vascular), ischemic heart disease (history of MI or current angina, use of SL NTG, positive stress test, Q waves on ECG, or history of PTCA/CABG with ongoing chest pain), history of CVA/TIA, diabetes requiring insulin, or creatinine > 2.0 mg/dl. If yes, give perioperative beta-blocker unless contraindicated.

3.      Beta-blocker treatment protocol:

• Preoperative: atenolol 50-100 mg PO QD or continue outpatient therapy if previously on beta-blocker (beta-1 selective).  Titrate dose to HR < 65.  If NPO, use atenolol or metoprolol 2.5-10 mg IV until target HR achieved.
• Immediately post-op: use atenolol or metoprolol 5-10 mg IV to achieve target HR.
• Postoperative: transition back to the preoperative oral therapy when the patient is ready to take PO’s.  If patient is unstable, consider using esmolol.  Beta-blocker should be continued at least 1 month postoperatively.

4.      Don’t treat the numbers: resist the urge to blindly treat tachycardia in the perioperative period with beta-blockers.  If a patient has new, unexplained tachycardia, investigate first.   In cases like this, tachycardia may be the only sign of a potentially dangerous underlying condition.

Auerbach AD, Goldman L. beta-Blockers and reduction of cardiac events in noncardiac surgery: scientific review. JAMA 2002; 287:1435-44.