A 64-year-old man on long-term metoprolol 50 mg twice daily for stable ischaemic heart disease is posted for elective hemicolectomy. Which perioperative management of this drug is MOST appropriate?
- A Continue metoprolol through the perioperative period, including the morning dose ✓
- B Omit the morning dose on the day of surgery
- C Withhold metoprolol and give intravenous esmolol only if hypertension develops
- D Discontinue metoprolol one week before surgery
Correct answer: A. Continue metoprolol through the perioperative period, including the morning dose
Explanation
Beta blockers taken chronically for established indications such as ischaemic heart disease should be continued throughout the perioperative period, including the morning of surgery. Abrupt withdrawal causes receptor upregulation and rebound tachycardia, hypertension and myocardial ischaemia. The caution applies to starting a beta blocker de novo on the day of surgery, which was associated with harm in the POISE trial, not to continuing long-term therapy. Reactive treatment with esmolol does not replace steady chronic beta blockade.
Reference: Katzung's Basic and Clinical Pharmacology, 16th ed.
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