Practical, Effective Use of Beta Blockers to Improve Perioperative Patient Outcomes

Although the science of identifying patients who are at highest risk for perioperative cardiac events (e.g., myocardial infarction [MI], unstable angina, congestive heart failure, and cardiac death) is well developed, the evidence to support how best to care for high-risk patients was, until recently, scanty and conflicting.1,2 The emergence of a literature supporting the efficacy and effectiveness of perioperative beta blockade to reduce the cardiac risks of surgery3–5 has helped to partially resolve the essential conundrum posed by virtually all guidelines addressing the perioperative care of the patient with known coronary disease or substantial risks for atherosclerosis: although preoperative testing algorithms uncover coronary disease, none of them supports preoperative revascularization unless the patient requires this procedure outside of surgery.1,2 Over the past nine years or so, a substantial number of welldesigned clinical studies have outlined the potential benefits of perioperative adrenergic blockade. Virtually all of these trials have demonstrated a substantial reduction in risk when applied effectively in appropriate patients. However, a parallel set of published studies indicates how current systems of care are ill equipped to deliver this important new therapy to suitable candidates.6–8 This article outlines the evidence base to support the use of perioperative beta blockers in patients undergoing major noncardiac surgery and describes several potential solutions to the organizational or other possible obstacles to effective implementation.