When should valsartan (an angiotensin II receptor blocker) be held or discontinued in patients, such as those with symptomatic hypotension, hyperkalemia, acute renal impairment, pregnancy, before iodinated contrast studies or major surgery, or severe volume depletion?

When to Hold Valsartan

Valsartan should be immediately discontinued upon pregnancy detection, and temporarily held for symptomatic hypotension, hyperkalemia (K+ ≥5.5 mmol/L), or acute significant renal impairment (creatinine doubling or >30% increase that doesn't stabilize). 1

Absolute Contraindications (Discontinue Immediately)

Pregnancy

• Discontinue valsartan as soon as pregnancy is detected 2, 1
• Causes fetal toxicity during second and third trimesters, including renal dysfunction, oligohydramnios, skull hypoplasia, and fetal death 1

Temporary Holds (Reassess and Resume When Resolved)

Symptomatic Hypotension

• Hold if systolic BP <90 mm Hg with symptoms 1
• In heart failure patients, some BP reduction is expected (5.5% incidence vs 1.8% placebo), but symptomatic hypotension requires intervention 1
• Management approach:
  • Place patient supine, give IV normal saline if needed
  • Stagger vasoactive medications by 2+ hours apart 3
  • Reduce or discontinue non-prognostic BP medications (calcium channel blockers, alpha-blockers) 3
  • A transient hypotensive response is NOT a contraindication to restarting once BP stabilizes 1

Hyperkalemia

• Hold if K+ ≥5.5 mmol/L 4, 5
• Monitor K+ closely, especially with:
  • Triple therapy (ACE-I/ARB + MRA + diuretics) 3
  • Pre-existing renal impairment 1
  • Acute dehydrating illnesses 3, 6
• Most clinicians stop the MRA first and reassess before stopping the ARB 3
• Check electrolytes every 1-3 months in stable patients, more frequently with triple therapy 3

Acute Renal Impairment

• Hold if creatinine increases >30% from baseline and doesn't stabilize 6, 1
• An increase up to 30% is acceptable and expected in many heart failure patients—does NOT require discontinuation if it stabilizes 6
• Reassess within 7 days if creatinine changes >20-30% 3
• Monitor renal function periodically in high-risk patients:
  • Renal artery stenosis
  • Chronic kidney disease
  • Severe heart failure
  • Volume depletion 1

Caution Situations (Use With Close Monitoring, Don't Necessarily Hold)

Volume Depletion

• Correct volume/salt depletion BEFORE starting valsartan or start under close supervision 1
• Patients on high-dose diuretics are at particular risk for symptomatic hypotension 1

Perioperative Management

• Controversial—no definitive guideline consensus
• One study showed discontinuing ARBs the day before surgery reduced severe hypotensive episodes during anesthesia induction 7
• However, 2024 AHA/ACC perioperative guidelines recommend continuing most antihypertensives perioperatively, with caution in patients at high risk for hypotension 8
• Practical approach: Consider holding 24 hours before major surgery in patients with borderline BP or high hypotension risk; restart as soon as clinically reasonable postoperatively 8

Contrast Studies

• Insufficient evidence to recommend routine discontinuation before coronary angiography 9
• Conflicting data on contrast-associated acute kidney injury risk
• Monitor renal function closely post-procedure

Common Pitfalls to Avoid

1. Don't stop valsartan for asymptomatic creatinine increases <30% that stabilize—this is expected and acceptable 6

2. Don't permanently discontinue for transient hypotension—correct the underlying cause and restart 1

3. Don't stop ARB before stopping MRA when managing hyperkalemia—most clinicians reverse this order 3

4. Don't fail to monitor electrolytes and creatinine in high-risk patients (every 1-3 months minimum) 3

5. Don't combine with ACE inhibitors—this increases risk without benefit 10

6. Avoid in renovascular disease without specialist supervision 2