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
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.