Beta Blockade Protocol & Cardiac Risk Stratification
Boyd, Rev. March '06

Beta (β) Blockade Protocol

Goal: HR <70 bpm for pre-induction, intra-op, and post-op
Included Patients
Class I Risk (1 or more present) Class II Risk (2 or more present)
Major Vascular Surgery
CABG or CABG hx
Known Ischemic Heart Dz (CAD)
Prior MI
CHF hx
Creatinine ≥ 2.0
Insulin-Dep. DM (IDDM, Type I)
Peripheral Vasc. Dz (PVD)
Cerebral Vasc. Event (CVD, Stroke)
Age>65
Hypertension
Smoker
Non-insulin-Dep DM (NIDDM, Type II)
Emergent Surgery
Excluded Patients Treatment   (omit for low-risk surgery)
Known sensitivity to β Blocker
HR<55, Systolic BP<100
2nd Degree Heart Block
3rd Degree Heart Block
Acute CHF
Acute bronchospasm
Pulmonary Dz treated w/ β agonist
Preop Clinic: start
    Metoprolol 25 mg po BID
Preop /IntraOp
    Metoprolol 5mg iv q 5' prn
Post-Op: Continue β blockade 
    at least 3 days
Goal: HR <70 bpm for pre-induction, intra-op, and post-op

Risk Stratification: Boyd 3/2006

Cardiac Risk* Stratification for 
Noncardiac Surgical Procedures

American Col. of Cardiology 2002

High Risk
(Reported cardiac risk 
often greater than 5%)
» Emergent major operations, particularly in the elderly
» Aortic and other major vascular surgery
» Peripheral vascular surgery
» Anticipated prolonged surgical procedures associated 
   with large fluid shifts and/or blood loss
Intermediate Risk
(Reported cardiac risk 
generally less than 5%)
» Carotid endarterectomy
» Head and neck surgery
» Intraperitoneal and intrathoracic surgery
» Orthopedic surgery
» Prostate surgery
Low Risk
(Reported cardiac risk 
generally less than 1%)
» Endoscopic procedures
» Superficial procedure
» Cataract surgery
» Breast surgery
*Combined incidence of cardiac death and nonfatal myocardial infarction.
†Do not generally require further preoperative cardiac testing or preop beta blockade

Rev 11/19/2009