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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e69 CLINICAL STATEMENTS AND GUIDELINES 1 to 2 hours before surgery experienced a composite outcome of death and thrombotic complications at 30 days and an incidence of major bleeding and cardiac tamponade that were similar to those seen with placebo.24 In the second trial,25 patients randomized to receive 300 mg of aspirin the night before surgery had increased episodes of major bleeding (>750 mL in 24 hours, or 1000 mL overall) and increased transfusion rates, but no significant differences were found in major cardiovascular events at early (30 days) or long-term (36 months) time points25 compared with placebo. 13.3 Beta Blockers and Amiodarone in Patients Undergoing CABG Recommendations for Beta Blockers and Amiodarone in Patients Undergoing CABG Referenced studies that support the recommendations are summarized in Online Data Supplement 43. COR LOE Recommendations 2a B-R 1. In patients undergoing CABG, who do not have a contraindication to beta blockers, the administration of beta blockers before surgery can be beneficial to reduce the incidence of postoperative atrial fibrillation.1-8 2a B-R 2. In patients undergoing CABG, preoperative amiodarone is reasonable to reduce the incidence of postoperative atrial fibrillation.9-11 2b B-NR 3. In patients undergoing CABG, who do not have a contraindication to beta blockers, preoperative use of beta blockers may be effective in reducing in-hospital and 30-day mortality rates.12-18 2b B-NR 4. In patients undergoing CABG, the role of preoperative beta blockers for the prevention of acute postoperative myocardial ischemia, stroke, AKI, or ventricular arrhythmia is uncertain.12-14,18 Synopsis In patients undergoing elective CABG, the risks and benefits of beta-blocker and amiodarone administration before surgery should be carefully considered. Although preoperative beta blockers are associated with reduced incidence of postoperative atrial fibrillation, recent data, including meta-analyses of RCTs and several large observational trials, have yielded conflicting results with regard to their impact on other outcomes, including death, MACE, and other arrhythmias. Recommendation-Specific Supporting Text 1. Several small RCTs1-5 and multiple meta-analyses of RCTs6-8 have investigated preoperative beta blockers and found that their use is associated with a reduced incidence of atrial fibrillation after CABG. Although the recommendation stems from what is considered high-quality evidence, full interpretation of the data is limited because the trials tended to incorporate multiple intervention arms, had variable timing of initiation of therapy, and were unable to establish the relative impact of preoperative beta-blocker administration in the context of postoperative use. The overwhelming majority of trials investigating the use of preoperative beta blockers are confounded by concomitant postoperative administration. As a result, the optimal agent selection, schedule, and duration to prevent atrial fibrillation are unclear. 2. Studies have demonstrated that preoperative prophylactic oral amiodarone significantly decreased the incidence of postoperative atrial arrhythmias and stroke and reduced hospital length of stay compared with placebo without any adverse complications other than occasional bradycardia.9,11,19 Amiodarone may cause toxicity or systemic hypotension, and thus its use is determined on an individualized basis, particularly in patients who are at high risk of developing atrial fibrillation. 3. Results from a large observational database suggested that preoperative beta-blocker administration was associated with a reduction in in-hospital and 30-day mortality rate after CABG.16 These findings underpin the inclusion of preoperative beta blockers as a quality indicator for CABG surgery. Newer observational studies have yielded more conflicting results,12-14 showing little or no mortality benefit, particularly when comparisons between propensity-matched participants are analyzed. Beta-blocker pharmacogenetic variation may have a role. One study found that, when compared with no preoperative beta blockers, noncytochrome P4502D6 metabolized agents (ie, atenolol and sotalol) were associated with a lower incidence of operative death; however, P4502D6 metabolized agents (ie, metoprolol, propranolol, carvedilol, and labetalol) were not.17 The impact of preoperative beta-blocker administration in patients with reduced left ventricular ejection fraction requires additional investigation.15,16 4. Observational studies do not reveal a consistent association between preoperative beta-blocker use and other postoperative outcomes, including myocardial ischemia, stroke or transient ischemic attack, and AKI.12-14 An area that likely requires further investigation is the efficacy of preoperative beta blockers in the prevention of ventricular arrhythmias. One meta-analysis of RCTs did suggest improved rates of ventricular arrhythmia, but most of the studies included the outcome as a secondary endpoint.6,18 Patients undergoing CABG who receive beta blockers are closely monitored for bradycardia or hypotension, with subsequent dose adjustment to avoid these adverse effects .4-7 Downloaded from http://ahajournals.org by on October 7, 2026