A 66-year-old man with two Revised Cardiac Risk Index factors is listed for elective open aortic aneurysm repair tomorrow. He has never taken a beta-blocker. His surgeon asks whether bisoprolol should be started tonight to reduce perioperative cardiac events. What is the most appropriate advice?

• A Start bisoprolol tonight, since beta-blockade lowers cardiac risk in all high-risk patients
• B Start bisoprolol only if the preoperative echocardiogram shows an ejection fraction below 50 percent
• C Give a single intravenous metoprolol dose immediately before induction instead of oral therapy
• D Do not initiate a beta-blocker on the day before or day of surgery, as this increases stroke and all-cause mortality ✓

Explanation

The POISE trial showed that initiating metoprolol shortly before non-cardiac surgery reduced non-fatal myocardial infarction but significantly increased stroke, hypotension, bradycardia, and all-cause mortality. Current guidance permits continuing beta-blockers in chronic users but forbids starting them on the day of surgery or immediately before it. Any initiation, if considered at all, must occur well in advance with careful titration. Ejection fraction does not determine the decision.

Reference: Miller's Anesthesia, 9th ed.

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Written and medically reviewed by the StethoPrep medical team.