What medications should be held in an elderly woman with a history of atrial fibrillation (a fib) and a pacemaker, who takes aspirin (ASA) 81 mg daily and metoprolol (Lopressor) 50 mg twice daily (bid), prior to surgery?

Perioperative Medication Management

Continue metoprolol through the morning of surgery and hold aspirin 7 days before surgery if possible, but if surgery is tomorrow morning, proceed with aspirin held the night before and continue metoprolol.

Metoprolol Management

Beta-blockers like metoprolol should NOT be routinely withdrawn prior to major surgery 1. The FDA label explicitly states that "chronically administered beta-blocking therapy should not be routinely withdrawn prior to major surgery" 1. While beta-blockers may impair the heart's ability to respond to reflex adrenergic stimuli during general anesthesia, the risks of abrupt discontinuation far outweigh these concerns 1.

• Give metoprolol on the morning of surgery with a sip of water 1. Abrupt discontinuation in patients with underlying coronary artery disease (which may be unrecognized) can precipitate severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 1.

• The pacemaker does not change this recommendation—the device provides backup pacing but does not protect against the adverse effects of acute beta-blocker withdrawal 1.

• For rate control in atrial fibrillation, beta-blockers remain the preferred first-line agent perioperatively 2.

Aspirin Management

Hold aspirin if surgery is not urgent, but given that surgery is scheduled for tomorrow morning, the aspirin taken today should be the last dose 3, 4.

• The POISE-2 trial (10,010 patients) demonstrated that perioperative aspirin administration had no significant effect on death or nonfatal myocardial infarction (7.0% vs 7.1%, HR 0.99, P=0.92) but significantly increased major bleeding (4.6% vs 3.8%, HR 1.23, P=0.04) 4.

• For patients on aspirin for primary prevention or atrial fibrillation alone (without coronary stents), aspirin should be discontinued perioperatively 5, 6, 4. This patient's indication appears to be atrial fibrillation management, not coronary artery disease with stenting.

• The bleeding risk must be weighed against thrombotic risk 3. In patients without recent coronary stents or acute coronary syndrome, the thrombotic risk of brief aspirin interruption is low 6.

Critical Exception - Coronary Stents

If this patient has a history of coronary stenting (not mentioned in the case), the management changes dramatically:

• Bare-metal stents: Aspirin must be continued if surgery occurs within 4-6 weeks of stent placement 3. After 4-6 weeks, aspirin should generally be continued unless high bleeding risk 3.

• Drug-eluting stents: Elective surgery should be deferred until 12 months after stent placement, and aspirin must be continued throughout the perioperative period 3. Premature discontinuation markedly increases the risk of catastrophic stent thrombosis, death, and myocardial infarction 3.

Anticoagulation Considerations

This patient should be on anticoagulation for stroke prevention, not just aspirin 3, 2. Atrial fibrillation with additional risk factors (elderly, likely has hypertension given beta-blocker use) warrants oral anticoagulation with either a vitamin K antagonist (INR 2.0-3.0) or a direct oral anticoagulant 3.

• If the patient is on warfarin (not mentioned), it can be held for up to 1 week for surgery in patients at low-to-moderate thromboembolic risk without bridging 3.

• If on a DOAC, hold for 1-2 days (depending on renal function) before surgery for procedures requiring complete hemostasis 3.

Practical Algorithm for Tomorrow's Surgery

1. Tonight: Hold aspirin (last dose was today) 4
2. Tomorrow morning: Give metoprolol 50 mg with small sip of water 2-4 hours before surgery 1
3. Verify: Confirm no history of recent coronary stenting (if present, aspirin continuation may be necessary despite bleeding risk) 3
4. Post-operatively: Resume metoprolol as soon as patient can take oral medications 1; resume aspirin once adequate hemostasis achieved, typically 24-48 hours post-op 3

Common Pitfalls to Avoid

• Never abruptly stop beta-blockers perioperatively—this is associated with rebound tachycardia, hypertension, and myocardial ischemia 1
• Do not assume aspirin is necessary for stroke prevention in atrial fibrillation—anticoagulation is superior and aspirin alone is inadequate for patients with risk factors 3, 2
• Do not continue aspirin if the patient has coronary stents without verifying the type and timing of stent placement—this determines whether continuation is mandatory 3
• Avoid holding both aspirin AND beta-blockers—this compounds cardiovascular risk unnecessarily 1, 4