Management of Postoperative Hypertension

Pathophysiology and Risk Assessment

Postoperative hypertension can occur due to various stimuli including pain, inflammation, anxiety, hypoxia, volume overload, urinary retention, or withdrawal of chronic antihypertensive medications 1
Hypertension in the perioperative period increases the risk of cardiovascular disease, cerebrovascular events, and bleeding 2
Patients with hypertension demonstrate a more labile hemodynamic profile than their non-hypertensive counterparts 3
Untreated postoperative hypertension can increase the risk for myocardial ischemia/infarction, acute decompensated heart failure, cerebral ischemia, and dysrhythmias 1

Check for volume overload which may contribute to postoperative hypertension 1
Resume losartan 50mg daily as soon as the patient can take oral medications, as recommended by the American Heart Association 2, 1
Delaying resumption of preoperative ACEi/ARBs has been associated with increased 30-day mortality risk 1

Higher doses of losartan (100-150mg) have shown better cardiovascular outcomes in clinical trials, similar to findings with ACE inhibitors, according to the European Society of Cardiology 4
The HEAAL trial showed a 10% relative risk reduction in death or heart failure hospitalization with losartan 150mg daily compared to 50mg daily 5

Avoid intensification of antihypertensive therapy at hospital discharge as this may increase the 30-day risk of readmission and serious complications, particularly in older adults, as stated by the American College of Cardiology 1
Avoid abrupt withdrawal of losartan as this may lead to rebound hypertension, as warned by the European Heart Association 6

Monitor blood pressure regularly in the postoperative period, particularly during the first 24-48 hours after resuming losartan, as recommended by the Anaesthesia society 3
Target blood pressure should be individualized based on the patient's baseline values, but generally maintaining systolic blood pressure <180 mmHg and diastolic blood pressure <110 mmHg is reasonable in the immediate postoperative period, according to the Anaesthesia society 3

Be cautious with volume status assessment, as hypovolemia can exacerbate hypotension when losartan is resumed, as advised by the American Heart Association 2
If the patient cannot take oral medications immediately after surgery, consider appropriate intravenous antihypertensive agents until oral intake is possible, as recommended by the American College of Cardiology 2