Would you administer a beta blocker prior to cardiac surgery to a patient on an Intra-Aortic Balloon Pump (IABP)?

From the Guidelines

I would generally avoid giving a beta blocker prior to cardiac surgery to a patient on an intra-aortic balloon pump (IABP). Beta blockers like metoprolol, atenolol, or carvedilol are typically contraindicated in patients requiring mechanical circulatory support from an IABP, as they can further reduce contractility and cardiac output, potentially precipitating cardiogenic shock or worsening existing hemodynamic instability 1. The most recent guidelines from 2024 suggest that routine initiation of a beta-blocker peri-operatively is not necessary, and that peri-operative continuation of beta-blockers is recommended for patients currently taking beta-blockers 1.

Key Considerations

• Patients on IABP already have compromised cardiac function, and adding a negative inotropic agent like a beta blocker could worsen their condition.
• The decision to continue or hold beta blockers in patients previously on beta blocker therapy should be made on a case-by-case basis in consultation with the cardiac surgical team and anesthesiologists.
• In specific situations where tachyarrhythmias are present despite IABP support, very cautious use of short-acting beta blockers like esmolol might be considered under close hemodynamic monitoring, but this would be the exception rather than the rule.

Guideline Recommendations

• The 2024 ESC guidelines for the management of elevated blood pressure and hypertension suggest that routine initiation of a beta-blocker peri-operatively is not necessary, but that peri-operative continuation of beta-blockers is recommended for patients currently taking beta-blockers 1.
• The 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery also recommends continuing beta blockers in patients who are on them chronically, but advises against initiating beta blockers on the day of surgery 1.

Clinical Judgment

• Clinical judgment should be used to titrate beta blockers as appropriate during the perioperative period, with a focus on ensuring the medication is continued through the hospital stay and at discharge unless clear contraindications arise 1.
• The potential benefits and harms of beta blockers should be carefully weighed, and the decision to initiate or continue beta blockers should be made on an individual basis, taking into account the patient's specific clinical circumstances and risk factors.

From the FDA Drug Label

2.2 Intraoperative and Postoperative Tachycardia and Hypertension

In this setting it is not always advisable to slowly titrate to a therapeutic effect.

2 DOSAGE & ADMINISTRATION

2.1 Dosing for the Treatment of Supraventricular Tachycardia or Noncompensatory Sinus Tachycardia Esmolol hydrochloride is administered by continuous intravenous infusion with or without a loading dose.

The FDA drug label does not answer the question.

From the Research

Administration of Beta Blocker Prior to Cardiac Surgery

• The decision to administer a beta blocker prior to cardiac surgery to a patient on an Intra-Aortic Balloon Pump (IABP) depends on various factors, including the patient's medical history, current condition, and the type of surgery being performed 2, 3, 4, 5, 6.
• Studies have shown that the use of IABP in high-risk patients prior to coronary artery bypass graft surgery can decrease the risk of morbidity and mortality 5.
• However, the use of beta blockers in patients with IABP is not directly addressed in the provided studies.
• The studies focus on the use of IABP in high-risk patients undergoing cardiac surgery, and the benefits of preoperative IABP support in reducing hospital mortality and shortening ICU stay 3, 4, 5.

Considerations for Beta Blocker Administration

• The patient's hemodynamic status and ability to tolerate beta blocker therapy should be carefully evaluated before administration 2.
• The potential benefits of beta blocker therapy, such as reducing myocardial oxygen demand and preventing arrhythmias, should be weighed against the potential risks, such as exacerbating heart failure or hypotension 6.
• The decision to administer a beta blocker should be made on a case-by-case basis, taking into account the individual patient's needs and medical history.

Intra-Aortic Balloon Pump Support

• IABP support has been shown to improve cardiac performance and reduce morbidity and mortality in high-risk patients undergoing cardiac surgery 3, 4, 5.
• The use of IABP can increase diastolic blood pressure, cardiac index, and endocardial viability ratio, while decreasing systolic blood pressure, left ventricular filling pressure, and peripheral resistance 2.
• Preoperative IABP support can be beneficial in high-risk patients, particularly those with severely impaired left ventricular function, acute myocardial infarction, or unstable angina 3, 4, 5.