Rationale for administering beta-blocker therapy to patients undergoing coronary artery bypass surgery: a systematic review

Abstract

Secondary preventative therapies are essential for patients undergoing coronary artery bypass graft (CABG) surgery to optimize perioperative and long-term outcomes. Beta-blockers are commonly used to treat patients with coronary artery disease and congestive heart failure (CHF), but their role for CABG patients remains unclear. The goal of this systematic review was to evaluate the rationale for administering beta-blockers to the CABG population and to assess their efficacy before and after coronary surgical revascularization. Areas covered: A systematic literature review was performed to retrieve relevant articles from the PubMed database published between 1985 and 2017. Expert opinion: Outside of the surgical field, strong evidence supports the use of beta-blockers for patients with a history of previous myocardial infarction (MI) or CHF. For the CABG population, studies have suggested that perioperative beta-blocker therapy is beneficial, with an associated reduction in mortality, particularly among those with a history of previous MI or CHF. Beta-blocker administration has also clearly been shown to lower the rate of new-onset postoperative atrial fibrillation after CABG. Among the different types of beta-blockers, perioperative carvedilol appears to be the most beneficial. In the absence of contraindications, nearly all CABG patients are candidates for perioperative beta-blocker therapy.

Effect of coronary artery bypass grafting on blood pressure response to head-up tilting

“…The Journal of Physiological Sciences αβ-blocker, calcium antagonist, angiotensin II receptor blocker and nitrates to prevent the development of postoperative atrial fibrillation [14,15] and recurrent myocardial infarction [16,17]. Diuretics keeps from causing fluid overload, which induces heart failure [17] and acute lung and kidney injuries [18], and making cardiac surgery patients to stay hospital for a longer length [19].…”

“…A decrease in BP after surgery further strengthened during HUT relative to that recorded before surgery, because hypovolemia might progress after CABG while cardiac function did not improve enough. Postoperative management involves procedures that prevent body-fluid overload, such as treatment with circulatory agonists and diuretics and limited intravenous fluid infusion [14][15][16][17][18][19]. Consequently, body weight decreased significantly by about 3 kg, relative to before surgery.…”

Preoperative β-blocker use correlates with worse outcomes in patients undergoing aortic valve replacement

“…32 Despite these recommendations, there is some evidence that patients with a history of previous myocardial infarction derive significant benefit from preoperative b-blockade, thus highlighting the necessity of meticulous preoperative evaluation and preparation and thoughtful patient selection before surgery. 33 In this study, approximately 8% of patients in the matched cohorts had a history of myocardial infarction, thus perhaps why this study did not demonstrate a significant benefit of preoperative b-blockade.…”

Fibrilação atrial no pós-operatório de cirurgia de revascularização do miocárdio: fatores de risco e evolução

“…Durante pré-operatório, os fatores são fortemente relacionados ao remodelamento cardíaco, disfunção diastólica e aumento do átrio esquerdo, como na fibrilação atrial clínica, sendo idade avançada e hipertensão arterial sistêmica de elevada relevância, e outras com papeis significativos, como insuficiência cardíaca, obesidade, DPOC e DRC. Contudo, a manutenção do uso de betabloqueadores, salvo em situação de instabilidade hemodinâmica e/ou bloqueios avançados atrioventriculares, foi associada a redução de risco de FAPO em 50% quando comparado ao grupo placebo (12). Não há, de modo geral, indicação específica para o tipo de betabloqueador, em análise de DiNicolantonio et al (2014), o carvedilol apresentou benefício adicional de até 50% frente ao metoprolol (12,13).…”

“…Contudo, a manutenção do uso de betabloqueadores, salvo em situação de instabilidade hemodinâmica e/ou bloqueios avançados atrioventriculares, foi associada a redução de risco de FAPO em 50% quando comparado ao grupo placebo (12). Não há, de modo geral, indicação específica para o tipo de betabloqueador, em análise de DiNicolantonio et al (2014), o carvedilol apresentou benefício adicional de até 50% frente ao metoprolol (12,13). Apesar de mecanismo ainda incerto, o betabloqueador age na redução de ativação simpática, permitindo redução da variabilidade dos intervalos R-R, reduzindo, assim, a entropia, como também, o carvedilol apresenta propriedades anti-inflamatórias, anti-oxidantes e antiarrítmicas distintas, podendo auxiliar frente ao estresse inflamatório e oxidativo no pós-operatório (12).…”