Should carvedilol (beta-blocker) be continued or discontinued in the preoperative period?

Perioperative Management of Carvedilol

Carvedilol should be continued perioperatively in patients already receiving this medication to prevent rebound hypertension, tachycardia, and potential exacerbation of coronary artery disease. 1, 2

Evidence-Based Rationale

The European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA) guidelines provide a Class I, Level B recommendation for perioperative continuation of beta-blockers in patients currently receiving this medication 1. This is strongly supported by the FDA drug label for carvedilol, which explicitly warns against abrupt discontinuation due to risks of severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 2.

Management Algorithm

For Patients Already on Carvedilol:

1. Continue carvedilol throughout the perioperative period (Class I recommendation) 1

   • Maintain the same dosage if hemodynamically stable
   • If necessary, switch to intravenous administration when oral intake is not possible 1

2. Monitor for potential adverse effects:

   • Bradycardia (if pulse drops below 55 beats/minute, reduce dosage) 2
   • Hypotension (maintain mean arterial pressure above 55 mmHg) 1
   • Heart failure exacerbation 2

Special Considerations:

• For liver transplant candidates: Patients already receiving carvedilol for prophylaxis against variceal bleeding should continue on this non-selective agent 1

• For patients with coronary artery disease: Beta-blockers are particularly important to continue due to their cardioprotective effects 1

• For patients with heart failure: Carvedilol should not be withdrawn in patients treated for stable heart failure due to left ventricular systolic dysfunction 1

Contraindications and Cautions

• Severe bradycardia or hypotension: Consider dose reduction rather than discontinuation 1, 2
• Decompensated heart failure: Adjust therapy to clinical condition 1
• Bronchospastic disease: Use with caution and at lowest effective dose 2

Common Pitfalls to Avoid

1. Abrupt discontinuation: This is specifically contraindicated and can lead to severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 2

2. Failure to monitor hemodynamics: Ensure heart rate remains above 55 bpm and mean arterial pressure above 55 mmHg 1, 2

3. Inappropriate dose increases: If tachycardia occurs postoperatively, first treat the underlying cause (hypovolemia, pain, blood loss, infection) rather than simply increasing the beta-blocker dose 1

4. Initiating beta-blockers immediately before surgery: This practice is not recommended (Class III recommendation) and may increase risk 1

Special Situations

• For patients with refractory ascites: Consider cardioselective beta-blockers instead of carvedilol 1

• For liver transplant candidates: Multidisciplinary discussion with anesthesiology input is recommended regarding continuation or discontinuation of beta-blocker therapy perioperatively 1

In conclusion, the evidence strongly supports continuing carvedilol in the perioperative period for patients already taking this medication, with appropriate monitoring and dose adjustments as needed to maintain hemodynamic stability.