Should metoprolol (beta blocker) be withheld before surgery?

From the Guidelines

Metoprolol should generally be continued up to and including the day of surgery. Patients taking metoprolol for hypertension, coronary artery disease, or heart failure should take their usual dose on the morning of surgery with a small sip of water. Abruptly stopping beta-blockers like metoprolol before surgery can lead to rebound hypertension, tachycardia, and increased risk of perioperative cardiac events, as noted in the 2009 ACCF/AHA focused update on perioperative beta blockade 1. The medication helps maintain hemodynamic stability during surgery by preventing spikes in heart rate and blood pressure that occur with surgical stress.

Some key points to consider when deciding whether to hold metoprolol before surgery include:

• The presence of active cardiac conditions, such as unstable coronary syndromes, decompensated heart failure, significant arrhythmias, or severe valvular disease, which may require intensive management and potentially delay or cancel surgery unless it is emergent 1.
• The importance of titrating the dose of metoprolol perioperatively to achieve adequate heart rate control and minimize the risks of hypotension and bradycardia, as recommended in the 2009 ACCF/AHA focused update on perioperative beta blockade 1.
• The potential benefits of continuing beta-blocker therapy in the perioperative period, including reduced risk of perioperative ischemia, myocardial infarction, and cardiovascular death, as noted in the 2007 ACC/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery 1.

However, in some specific situations, the anesthesiologist or surgeon might recommend holding the medication, particularly if the patient has severe bradycardia, hypotension, or certain types of planned procedures. It is essential to discuss medications with the surgical team during the preoperative evaluation, as they may have specific instructions based on the individual health status and the type of surgery being undergone.

From the FDA Drug Label

Chronically administered beta-blocking therapy should not be routinely withdrawn prior to major surgery; however, the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia and surgical procedures

• Do not routinely withdraw metoprolol before major surgery, as this may increase the risk of certain complications, such as those related to general anesthesia and surgical procedures 2.
• It is recommended to continue metoprolol therapy as usual, unless otherwise advised by a physician.

From the Research

Holding Metoprolol Before Surgery

• The decision to hold metoprolol before surgery is complex and depends on various factors, including the type of surgery, patient's medical history, and current health status 3, 4.
• Studies have shown that metoprolol may not attenuate myocardial beta-adrenergic receptor desensitization during cardiac surgery, but it can reduce the incidence of supraventricular arrhythmias 3.
• However, other studies have found that preoperative metoprolol is associated with an increased risk of perioperative stroke, particularly in noncardiac surgery 4.
• In contrast, esmolol, an ultra-short-acting beta-blocker, has been shown to reduce the incidence of myocardial ischemia and arrhythmias in cardiac surgery, but it can also increase the risk of bradycardia and hypotension 5, 6.

Considerations for Metoprolol Use

• Metoprolol is generally well tolerated, but its use can be controversial, particularly in patients with certain medical conditions, such as asthma or diabetes 7.
• The use of metoprolol during the early stages of myocardial infarction is also controversial, and its benefits may not outweigh the risks in all patients 7.
• In cardiac surgery, the administration of metoprolol or esmolol should be carefully considered, taking into account the patient's individual risk factors and medical history 3, 5, 6.

Alternatives to Metoprolol

• Other beta-blockers, such as atenolol, may be considered as alternatives to metoprolol in certain situations, particularly in patients who are at high risk of stroke or other complications 4.
• The choice of beta-blocker and the decision to hold or continue it before surgery should be made on a case-by-case basis, taking into account the latest evidence and guidelines 3, 5, 7, 6, 4.