Case 2: Does this patient need a beta-blocker?

Preoperative Care of Patients with Kidney Disease
Author: V. Dimov, M.D., Department of General Internal Medicine, Cleveland Clinic

72 yo female with DM2 on insulin, HTN, CKD with creatinine 2.5 mg/dL and a history of stroke 2 years ago is here for preoperative evaluation for colon cancer surgery. METs 5.

Does she need a beta-blocker in the perioperative period?

Yes. CKD with serum creatinine higher than 2 mg/dL is a part of the Revised Cardiac Risk Index.

Revised Cardiac Risk Index (Circulation. 1999;100:1043-1049):

High-risk type of surgery
Ischemic heart disease
History of congestive heart failure
History of cerebrovascular disease
Insulin therapy for diabetes
Preoperative serum creatinine >2.0 mg/dL

4CD is a mnemonic to remember the risk factors in RCRI:

CAD
CHF
CVA
CKD
DM

If the patient has 2 or more points from RCRI, beta-blocker use in the perioperative period is recommended. Ideally, a long-acting beta blocker should be started 2-4 weeks before the surgery and continued for 2-4 weeks after the surgery.

Examples of long-acting beta-blockers are Atenolol and Toprol XL. The beta-blocker should be taken the morning before the surgery with a few sips of water. The target heart rate is 60 bpm.

Contraindications to starting a beta-blocker are: HR less than 60 bpm, SBP less than 110, AV block higher than 1st degree, asthma with active wheezing, and allergy to the medication.

Summary

Serum creatinine higher than 2 mg/dL is a part of the Revised Cardiac Risk Index that helps determine which patient may benefit from a beta-blocker.

References

ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery, 2007. Compare to 2002 version.
Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery. Thomas H. Lee et al. Circulation. 1999;100:1043-1049.
Preoperative Care of Patients with Kidney Disease. Mahesh Krishnan, M.D., M.P.H. Am Fam Physician 2002;66:1471-6.
Using beta-blockers to cut perioperative risk in CAD. Clinical vignettes on perioperative beta blockers. Archana Roy, MD; Vivek Roy, MD. Postgraduate Medicine, Vol. 118, No. 6, 12/05.
Perioperative Management of the Patient With Chronic Renal Failure. Kenneth E Otah, MD, MSc, Moro O Salifu, MD, MPH, Eseroghene Otah, MD. eMedicine.com, last accessed 3/7/06, eMedicine.com/med/topic3166.htm.

Further reading

Perioperative beta blockers: not so fast! Notes from Dr. RW, 07/2007.

Image source: public domain

Created: 5/30/2006
Updated: 03/31/2008