Should a patient stop taking carvedilol (beta blocker) before surgery?

Perioperative Management of Carvedilol

Patients currently taking carvedilol should continue the medication through the day of surgery and throughout the perioperative period. 1, 2, 3

Key Recommendations for Chronic Beta Blocker Users

Continue carvedilol without interruption in patients already receiving it for established indications (heart failure, coronary artery disease, hypertension, arrhythmias). 1, 2 The 2024 AHA/ACC guideline explicitly states that beta blockers should be continued through the perioperative period as appropriate based on clinical circumstances. 1

• Abrupt discontinuation of beta blockers is potentially harmful and can precipitate rebound hypertension, myocardial ischemia, or acute cardiac events. 1, 2
• The FDA label for carvedilol specifically states that "chronically administered beta blocking therapy should not be routinely withdrawn prior to major surgery." 3
• Beta blockers should be reinstituted as soon as possible after surgery in all patients without contraindications. 1

Critical Timing Considerations

Never initiate carvedilol on the day of surgery in beta blocker-naïve patients, as this significantly increases postoperative mortality and stroke risk. 1, 2 The POISE trial demonstrated that high-dose beta blockers started on the day of surgery increased all-cause mortality despite reducing cardiac events. 1, 2

• If a new indication for beta blockade exists, initiate carvedilol at least 7 days before elective surgery (optimally >7 days) to permit dose titration and assessment of tolerability. 1, 2
• Patients who initiated beta blockers <7 days before surgery had higher mortality compared to those who started >31 days earlier. 1, 2

Perioperative Dosing Strategy

Titrate carvedilol to heart rate and blood pressure targets during the perioperative period rather than using fixed high doses. 1

• Target heart rate of 60-80 beats per minute while maintaining systolic blood pressure >100 mm Hg. 1
• Use clinical judgment to adjust doses based on hemodynamic status, avoiding abrupt changes unless mandated by the patient's condition. 1, 4
• Monitor closely for hypotension and bradycardia, which are the most common complications requiring dose adjustment. 4

Special Surgical Considerations

The impaired ability of the heart to respond to reflex adrenergic stimuli may augment risks of general anesthesia, but this does not justify routine withdrawal. 3

• Anesthesiologists should be informed that the patient is taking carvedilol to anticipate potential hemodynamic responses. 3
• Patients on carvedilol may be unresponsive to usual doses of epinephrine if anaphylaxis occurs. 3
• For cataract surgery specifically, carvedilol's alpha-blocking properties may cause Intraoperative Floppy Iris Syndrome (IFIS), but stopping the medication prior to surgery provides no benefit. 3

Risk-Benefit Analysis by Patient Population

High cardiac risk patients (coronary artery disease, heart failure, multiple cardiac risk factors) derive the greatest benefit from continuing carvedilol perioperatively. 1

CABG patients should receive beta blockers for at least 24 hours before surgery to reduce postoperative atrial fibrillation, and carvedilol should be continued in those already taking it. 1

Liver transplant candidates already receiving carvedilol for variceal bleeding prophylaxis should continue the medication, as it should not be started in the immediate perioperative period but maintained if already prescribed. 1

Common Pitfalls to Avoid

• Do not stop carvedilol abruptly due to concerns about intraoperative hypotension—the risks of withdrawal exceed the risks of continuation. 1, 2
• Do not withhold the morning dose on the day of surgery in chronic users. 1, 2
• Do not start carvedilol in the immediate preoperative period (<7 days) or on the day of surgery in previously untreated patients. 1, 2
• Do not use high fixed doses without titration—this was the harmful approach in the POISE trial. 1, 2