Is starting a patient on beta blockers (beta-adrenergic blocking agents) mandatory prior to Endovascular Aneurysm Repair (EVAR)?

Is Starting Beta Blockers Mandatory Prior to EVAR?

No, starting beta blockers is not mandatory prior to EVAR, but the decision depends on the patient's cardiac risk profile and whether they are already on beta blockers for established indications. 1

Risk-Stratified Approach to Beta Blocker Initiation

Class I Recommendation: Continue Existing Beta Blockers

• Patients already on beta blockers for guideline-indicated conditions (coronary artery disease, heart failure, arrhythmias, hypertension) must continue them perioperatively. 1, 2
• Abrupt discontinuation increases risk of adverse cardiac events and should be avoided. 2
• Active management during and after surgery is required, with attention to hypotension, bradycardia, or bleeding that may necessitate temporary dose modification. 1, 2

Class IIb Recommendations: Consider Initiating Beta Blockers

For patients NOT currently on beta blockers, initiation may be reasonable in specific high-risk scenarios:

High-Risk Ischemia on Preoperative Testing

• It may be reasonable to begin beta blockers in patients with intermediate- or high-risk myocardial ischemia documented on preoperative stress testing. 1
• The decision must weigh stroke risk and other contraindications (uncompensated heart failure). 1

Multiple RCRI Risk Factors (≥3)

• In patients with 3 or more Revised Cardiac Risk Index (RCRI) risk factors (diabetes, heart failure, coronary artery disease, renal insufficiency, cerebrovascular disease), it may be reasonable to initiate beta blockers before surgery. 1
• Observational data suggest potential benefit in this population, though evidence is not definitive. 1

Patients with 1-2 RCRI Risk Factors

• The benefit of initiating beta blockers is uncertain in patients with only 1-2 RCRI risk factors. 1
• Even with a long-term indication for beta blockers but no additional RCRI criteria, perioperative initiation for risk reduction is of uncertain benefit. 1

Class III Recommendations: Do NOT Initiate Beta Blockers

Critical contraindications and harmful practices:

• Never start beta blockers on the day of surgery in beta-blocker-naïve patients—this is ineffective and potentially harmful. 1
• Do not use high-dose beta blockers without dose titration, as this increases stroke risk (1.0% vs 0.5%) and mortality (3.1% vs 2.3%). 1, 3
• Avoid in patients with absolute contraindications to beta blockade. 1

Timing and Titration Protocol

If beta blockers are initiated:

• Start preferably 2-7 days before surgery (not >30 days beforehand) to assess safety and tolerability. 1
• Starting ≤1 day before surgery is ineffective and may be harmful. 1
• Titrate to heart rate and blood pressure targets. 1, 2
• Clinical assessment for tolerability is more important than "tight" heart rate control, as evidence for aggressive titration is weak. 1

Evidence Quality and Nuances

The evolution of perioperative beta blocker recommendations reflects important safety concerns:

• Early small trials suggested large benefits, leading to widespread adoption. 1
• The POISE trial (>8000 patients) demonstrated that high-dose, fixed-dose metoprolol started on the day of surgery increased stroke and mortality risk, fundamentally changing practice. 1
• Current guidelines reflect a more nuanced, risk-stratified approach rather than universal application. 1
• Meta-analyses show no difference in major adverse cardiovascular events between continuation and withholding strategies when properly managed. 4

Common Pitfalls to Avoid

• Do not routinely start beta blockers in all EVAR patients—this is not supported by evidence and may cause harm. 1
• Do not use long-acting, high-dose formulations without titration in beta-blocker-naïve patients. 1
• Do not forget to restart beta blockers postoperatively if they were held, as soon as clinically feasible. 4, 2
• Do not ignore stroke risk factors when considering beta blocker initiation, particularly in elderly patients or those with cerebrovascular disease. 1, 3
• Ensure clear communication about medication management on the morning of surgery to prevent confusion. 4