Perioperative Management of Antihypertensive Medications

Rationale for Holding Angiotensin Receptor Blockers

The European Society of Cardiology recommends that transient discontinuation of ACE inhibitors and ARBs before non-cardiac surgery should be considered in hypertensive patients to reduce the risk of intraoperative hypotension and hemodynamic instability 1, 2
Perioperative use of angiotensin receptor blockers like telmisartan carries a significant risk of severe hypotension during anesthesia, particularly following induction, and can impair the response to vasopressors 1

Telmisartan should be discontinued 24 hours before surgery when prescribed for hypertension to allow for reduction in the risk of severe intraoperative hypotension while minimizing the risk of rebound hypertension 1, 2

The European Society of Cardiology guidelines explicitly recommend that hypertensive patients discontinue low-dose diuretics on the day of surgery to prevent volume depletion and electrolyte disturbances that may increase the risk of perioperative hypotension and arrhythmias 3, 4
Diuretics can cause hypokalaemia, which is reported in up to 34% of patients undergoing surgery and is associated with increased risk of ventricular arrhythmias and perioperative mortality 3, 4

In patients with heart failure, diuretics should be continued up to the day of surgery, resumed intravenously perioperatively, and continued orally when possible to maintain optimal volume status and prevent complications 3, 4
Electrolyte disturbances, especially hypokalemia and hypomagnesemia, should be corrected before surgery to reduce the risk of perioperative arrhythmias and other complications 3, 4

Both telmisartan and HCTZ should be resumed orally as soon as clinically possible after surgery to maintain blood pressure control and prevent potential complications 1, 3
Delaying the resumption of preoperative ACE inhibitors/ARBs has been associated with increased 30-day mortality risk, highlighting the importance of timely restart of these medications 5

The American College of Cardiology and American Heart Association recommend that discontinuation of angiotensin receptor blockers perioperatively may be considered in patients undergoing major surgery, based on moderate-quality evidence showing increased risk of intraoperative hypotension 6, 7
The American College of Cardiology guidelines provide a Class IIb recommendation for discontinuation of ARBs perioperatively, reflecting moderate-quality evidence 6, 7

Patients on angiotensin receptor blockers have an increased risk of intraoperative hypotension, which is associated with greater incidence of perioperative cardiac and renal complications 8, 9, 10
Blood pressure should be well-controlled (consistently <180/110 mm Hg) before discontinuing ARBs 6, 7

The American College of Cardiology recommends proceeding with discontinuation of ARBs if blood pressure is well-controlled and the patient has no acute heart failure or recent decompensation 6, 7, 8
The American College of Cardiology suggests considering continuing ARBs if the patient has severe, difficult-to-control hypertension requiring multiple agents or a recent history of hypertensive urgency or emergency 8

The American College of Cardiology advises against abruptly discontinuing ARBs if the patient is also on beta-blockers or clonidine, to avoid potentially harmful rebound hypertension 6, 7
The American College of Cardiology recommends ensuring the patient is euvolemic before surgery if cardiomegaly is present, as this affects the safety of withholding the ARB 8, 9, 10

The American College of Cardiology recommends resuming ARBs as soon as the patient is euvolemic and tolerating oral medications, typically within 24 hours postoperatively 8, 9, 10
The American College of Cardiology advises ensuring adequate volume status before restarting ARBs to minimize the risk of postoperative renal dysfunction 8, 9, 10