1. General Guidelines: The 7 Rules

It is difficult to make a protocol for all hospitals because systems work in different ways. However, there are seven (7) basic rules that should be followed.

Rules 1 - 3:

1. All patients who either have coronary artery disease (CAD), peripheral vascular disease (PVD), or two risk factors for coronary artery disease (age > 65, cigarette smoking, diabetes, hypertension, cholesterol > 240 mg/dl) should be on perioperative beta blockade unless they have a specific intolerance to beta blockers. Patients with renal failure or renal insufficiency may also benefit from therapy.

2. If a patient has an absolute contraindication to perioperative beta blockers, clonidine may be used as an alternative. Clonidine should be administered as follows.

3. Beta blockade should be started as soon as the patient is identified as having CAD, PVD, or risk factors. If the surgeon identifies the patients as having risk, the surgeon should start the medication. If the anesthesia preop clinic identifies the patient, it should be started in the preop clinic. If the patient is not identified until the morning of surgery, intravenous atenolol or metoprolol should be used. If the drug is started prior to the day of surgery, Atenolol 25 mg PO QD is an appropriate starting dose.