7. Implementing a Beta Blocker Protocol
General Guidelines for the Adoption of BBAC (Beta Blocker & Clonidine) Therapy
It is difficult to make a protocol for all hospitals because systems work in different ways. However, there are a few basic rules that should be followed.
1. All patients who either have coronary artery disease (CAD), peripheral vascular disease (PVD), or two risk factors for coronary artery disease (age > 65, cigarette smoking, diabetes, hypertension, cholesterol > 240 mg/dl) should be on perioperative beta blockade unless they have a specific intolerance to beta blockers. Patients with renal failure or renal insufficiency may also benefit from therapy.
2. If a patient has an absolute contraindication to perioperative beta blockers, clonidine may be used as an alternative. Clonidine should be administered as follows.
3. Beta blockade should be started as soon as the patient is identified as having CAD, PVD, or risk factors. If the surgeon identifies the patients as having risk, the surgeon should start the medication. If the anesthesia preop clinic identifies the patient, it should be started in the preop clinic. If the patient is not identified until the morning of surgery, intravenous atenolol or metoprolol should be used. If the drug is started prior to the day of surgery, Atenolol 25 mg PO QD is an appropriate starting dose.
4. Beta blockade should be continued until at least 30 days postoperatively.
5. The optimal time to start beta blockade is at the time of identification of the risk. This process should be multi-tiered to avoid missing patients. The culture must change for the maximal number of patients to be treated. We use the following approach.
6. Preoperative testing should be used as needed. If a patient is identified with new onset angina, unstable angina, a change in the anginal pattern, or congestive failure the further risk stratification is appropriate. If the patient is stable with known CAD, PVD, or two risk factors for CAD, they should be placed on a beta blocker.
7. Care should be taken with patients who are in congestive heart failure (CHF), aortic stenosis, or renal failure. All patients who have CHF should be evaluated by cardiology for the initiation of beta blocker therapy. Beta blocker therapy has been shown in multiple studies to reduce the risk of death from CHF. Many patients with CHF are profoundly improved by beta blockade. Patients with aortic stenosis should be evaluated by cardiology and beta blockade initiated with cardiology supervision. Patients with renal failure should be treated with agents but special attention is needed.