Should metoprolol be held in a 68-year-old patient with cardiovascular disease before surgery?

Perioperative Management of Metoprolol in a 68-Year-Old Patient

Metoprolol should be continued perioperatively in a 68-year-old patient with cardiovascular disease who is already taking this medication. 1

Evidence-Based Rationale

The American College of Cardiology/American Heart Association guidelines provide clear direction on this issue:

• Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers for treatment of conditions with ACCF/AHA Class I guideline indications (Level of Evidence: C) 1
• Abrupt discontinuation of beta blockers in patients with coronary artery disease can lead to severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 2

Risk Assessment

For a 68-year-old patient with cardiovascular disease, several factors must be considered:

• Age over 65 is itself a risk factor for perioperative cardiovascular complications
• Patients with established cardiovascular disease benefit from continued beta blockade through the perioperative period
• The POISE trial demonstrated that while initiating high-dose beta blockers immediately before surgery increased mortality, this does not apply to patients already on established beta blocker therapy 1

Management Algorithm

1. Preoperative Assessment

   • Verify the indication for metoprolol (hypertension, coronary artery disease, heart failure, arrhythmia)
   • Check vital signs, particularly heart rate (ensure it's not bradycardic, ideally 60-80 bpm) 1
   • Assess for any contraindications to continuing beta blockade (severe bradycardia, hypotension, high-degree heart block)

2. Day of Surgery

   • Administer the usual dose of metoprolol on the morning of surgery with a small sip of water
   • Monitor heart rate and blood pressure closely during the perioperative period
   • If oral administration is not possible postoperatively, consider IV metoprolol at equivalent dosing until oral intake is resumed 2

3. Postoperative Management

   • Resume oral metoprolol as soon as the patient can take medications by mouth
   • Continue to monitor for bradycardia, hypotension, or heart block
   • Ensure metoprolol is included in discharge medications

Important Caveats

• Never abruptly discontinue metoprolol: This can precipitate rebound hypertension, tachycardia, or angina exacerbation 2
• Dose titration may be needed: If hemodynamic instability occurs, temporary dose reduction rather than complete discontinuation is preferred 1
• Monitoring requirements: Close monitoring of heart rate and blood pressure is essential, especially in the immediate postoperative period 1

Special Considerations

• If the patient develops significant hypotension or bradycardia perioperatively, temporarily hold the dose and consult cardiology, but do not discontinue therapy completely without a plan for reintroduction 2
• For patients with heart failure, metoprolol provides mortality benefit and should be continued unless hemodynamically unstable 1

The evidence strongly supports continuing metoprolol throughout the perioperative period in patients already receiving this medication for cardiovascular indications, as the risks of discontinuation outweigh the potential risks of continuation 1, 2.