3. American College of Cardiology & American Heart Association Recommendations

Several things must be remembered about these indications. If you do not follow a class I recommendation you are not following standard of care and may be entangled in a malpractice claim. So, please, if you do anything, follow level I indications. Beta-blockers required in the recent past to control symptoms of angina or patients with symptomatic arrhythmias or hypertension. Unfortunately, in a recent epidemiologic analysis of patients undergoing CABG surgery fully 40% had their beta blockers discontinued with significant associated morbidity and mortality. BAD DOCTOR, Don't Discontinue Perioperative Beta Blockers. Perioperative Beta-blocker should be administered to patients at high cardiac risk owing to the finding of ischemia on preoperative testing who are undergoing vascular surgery.

So what does this mean?
Every patient with known coronary artery disease or vascular disease should be on a perioperative beta blocker unless there is a specific contraindication (asthma, allergy,or high grade AV block).

What about the people who have risk factors? It is a IIa recommendation which means you can't be sued for not doing it but it the weight of evidence or opinion is in favor of usefulness/ efficacy. Which means BBAC for patients at risk.

What about clonidine? Well, when the AHA/ACC guidelines were being published the panel was aware of the clonidine research (Wallace et. al. 2004) but it had not been published. When these guidelines are reviewed, clonidine BBAC will most likely be added to the class I or IIa recommendations.

Now what about that complex diagram? I put it in. You are supposed to follow it. I counted and there are eight (8) steps and forty-five arrows (45). You need 4 more steps to make a twelve step program. Needless to say, it is very hard to actually follow and few physicians really do.