Perioperative Management of Angiotensin Receptor Blockers (ARBs) in Patients with Elevated Blood Pressure

Guideline-Based Recommendation

The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend that ARBs be discontinued 24 hours before noncardiac surgery, as recent cohort evidence demonstrates lower rates of death, stroke, myocardial injury, and intraoperative hypotension compared to those continuing these medications until surgery, with a strength of evidence based on current evidence-based approaches 3, 2

If blood pressure is ≥180/110 mmHg, consider deferring elective major surgery until better control is achieved, according to the ACC/AHA guidelines 3, 1
Target blood pressure <130/80 mmHg is reasonable before undertaking major elective procedures, though this should be achieved with medications other than ARBs in the immediate preoperative period, as recommended by the American Heart Association 4, 1

Beta blockers must be continued if the patient is already taking them chronically to avoid rebound hypertension, as recommended by the ACC/AHA guidelines 3, 5, 1
Calcium channel blockers should be continued through the day of surgery as they do not cause significant intraoperative hypotension, according to the ACC/AHA guidelines 2
Alpha-2 agonists (clonidine) must be continued to avoid rebound hypertension, as recommended by the American Heart Association 3, 5

If hypertension develops intraoperatively after ARBs have been held, use IV antihypertensive agents such as clevidipine, esmolol, or nicardipine until oral medications can be resumed postoperatively, as recommended by the American Heart Association 4, 1, 5, 1

Do not continue ARBs on the day of surgery even with elevated blood pressure, as the risk of severe intraoperative hypotension creates greater morbidity risk than short-term hypertension, according to the ACC/AHA guidelines 2
Do not abruptly stop beta blockers or clonidine if the patient is taking them, as this creates rebound hypertension that is more dangerous than the controlled discontinuation of ARBs, as recommended by the American Heart Association 3, 1

Restart ARBs once the patient is hemodynamically stable and volume status is adequate, and monitor blood pressure closely after restarting to prevent postoperative hypotension, as recommended by the ACC/AHA guidelines 2
Resume ARBs as soon as clinically feasible when oral intake is tolerated, according to the ACC/AHA guidelines 2

For patients with left ventricular systolic dysfunction, there is nuanced guidance suggesting ARBs may be continued under close monitoring, but this represents a specific exception requiring individualized hemodynamic monitoring rather than routine practice, as recommended by the American College of Cardiology 2