Perioperative Management of Antihypertensive Medications

ARB Management

The American College of Cardiology recommends discontinuation of ARBs 24 hours before major surgery to reduce the risk of intraoperative hypotension, with a strength of evidence based on recent cohort studies 1, 3
If ARBs are held before surgery, the American College of Cardiology suggests they should be restarted as soon as clinically feasible postoperatively when volume status is stable, based on guidelines from the Journal of the American College of Cardiology 4, 3
For patients with left ventricular systolic dysfunction, the European Society of Cardiology recommends continuing ARBs perioperatively under close monitoring, with a moderate strength of evidence 5, 6
Perioperative use of ARBs carries a risk of severe hypotension under anesthesia, particularly following induction and with concomitant β-blocker use, according to the European Heart Journal 5, 6
Recent evidence from a large cohort study demonstrates that patients who stopped their ARBs 24 hours before noncardiac surgery were less likely to suffer the primary composite outcome and intraoperative hypotension than those continuing these medications until surgery, as reported in Circulation 1

The European Society of Cardiology recommends that calcium channel blockers can generally be continued during non-cardiac surgery, with a high strength of evidence 5
Heart rate-reducing calcium channel blockers, particularly diltiazem, may be considered before non-cardiac surgery in patients who have contraindications to β-blockers, according to the European Heart Journal 5
Calcium channel blockers are recommended to be continued during non-cardiac surgery in patients with Prinzmetal angina pectoris, based on guidelines from the European Society of Cardiology 5
Unlike ARBs, CCBs do not typically cause significant intraoperative hypotension that would warrant discontinuation, as stated in the European Heart Journal 5
Calcium channel blockers have been shown to significantly reduce ischemia and supraventricular tachycardia in the perioperative period, according to the Journal of the American College of Cardiology 4

For patients with planned elective major surgery and high blood pressure, deferring surgery may be considered, based on recommendations from the American College of Cardiology 1, 7
Patients with intraoperative hypertension should be managed with intravenous medications until oral medications can be resumed, according to guidelines from the American College of Cardiology 1, 7
For patients with left ventricular systolic dysfunction, continuing ARBs perioperatively under close monitoring may be beneficial, as recommended by the European Society of Cardiology 5, 6

ARBs should be restarted postoperatively once the patient is hemodynamically stable, based on guidelines from the Journal of the American College of Cardiology 4, 3
Ensure volume status is adequate before restarting ARBs to prevent postoperative hypotension, as recommended by the American College of Cardiology 3, 6
Monitor blood pressure closely after restarting ARBs or CCBs, according to guidelines from the American College of Cardiology 1, 5