β‐Receptor Blocker Withdrawal. A Preoperative Problem in General Surgery?

Abstract

A prospective randomized study was performed in 91 patients scheduled for general surgery on 99 occasions. The patients were chronically ( > 3 months) treated with P-receptor blockers because of ischaemic heart disease and/or hypertension and the P-receptor blockade was either gradually withdrawn (n=51) during 4 days preoperatively or continued until surgery (n=48). The effects on arterial blood pressure (BP), heart rate (HR) and rate-pressure product (RPP) at rest and the incidence ofchest pain duringdaily activities were registered. A withdrawal of the 0-receptor blockade was associated with increases of H R (in eight patients>30 beats min-') and RPP and in patients treated for hypertension there were also increases of systolic and diastolic BP (in five patients 230/15 mmHg). Patients who continued the P-receptor blockade until surgery showed no changes. Nine out of 23 patients with a previous history of ischaemic heart disease had a n increase of chest pain after withdrawal of the 0-receptor blockers, whereas none of the corresponding 25 patients who continued the therapy suffered from an increased chest pain. Due to the severity of symptoms after P-receptor blocker withdrawal, surgery had to be postponed in 4 patients. The observations suggest that a 4-day preoperative withdrawal of long-term e-receptor blockade is potentially hazardous in ischaemic and/or hypertensive patients.

Cardiovascular Pharmacotherapeutic Considerations in Patients Undergoing Anesthesia

“…12 The evidence for this recommendation was mainly on the basis of the body of literature pertaining to the dangers of beta blocker withdrawal that has been accumulating for more than 3 decades. 13,14 Not only is perioperative withdrawal of beta blockade associated with myocardial ischemia, but a recent prospective cohort study also showed that the risk of myocardial infarction (MI) increased substantially by withdrawal of cardioselective beta blockade. 15 The reasons for developing beta blocker withdrawal complications, which typically begins 72 hours after cessation of the drugs, include heightened sensitization to endogenous catecholamines, resulting in an increase in sympathetic nervous system activity.…”

Safety of perioperative β-blocker use: how do β-blockers compare in terms of side effects?

“…It might contribute to adverse myocardial outcome because of a rebound effect, resulting in increased HR, blood pressure and plasma noradrenalin concentrations [55][56][57][58][59]. Redelmeier et al demonstrated that longer acting b-blockers (such as atenolol) have a better perioperative cardiac protective action than short-acting drugs (metoprolol), probably as a result of acute withdrawal effects from missed doses of short-acting b-blockers [60].…”

“…Therefore, b-blockers should be continued in patients already using them [16,[57][58][59][60][61][62][63][64] COPD: Chronic obstructive pulmonary disease; FEV-1: Forced expiratory volume in one second.…”

Pharmacotherapeutic Considerations in Anesthesia

“…28,28a There is some concern among anesthesiologists that continuing ␤-blocker therapy into the perioperative period could attenuate or mask the physiologic responses to anemia, hypoxia, and hypercarbia. 29 However, abrupt withdrawal of these medications may sensitize patients to endogenous catecholamines, resulting in hypertension, tachycardia, arrhythmias, and myocardial ischemia. 30 -31a In one study, Ponten et al 29 examined the effects of slow withdrawal of ␤-blockers in 91 patients chronically treated with a ␤-blocker and scheduled to undergo general anesthesia.…”

“…29 However, abrupt withdrawal of these medications may sensitize patients to endogenous catecholamines, resulting in hypertension, tachycardia, arrhythmias, and myocardial ischemia. 30 -31a In one study, Ponten et al 29 examined the effects of slow withdrawal of ␤-blockers in 91 patients chronically treated with a ␤-blocker and scheduled to undergo general anesthesia. The control group continued taking the ␤-blocker up to the morning of surgery, while the experimental group was withdrawn from ␤-blocker therapy withdrawn during a 4-day period before the surgery.…”