Should You Take These Medications on the Morning of Your Endoscopy?
Continue carvedilol on the morning of your endoscopy, but hold both hydralazine and losartan on the day of the procedure.
Beta-Blocker (Carvedilol) - CONTINUE
The 2024 AHA/ACC perioperative guideline provides clear direction: beta blockers should be continued through the perioperative period in patients on stable doses 1. The FDA labeling for carvedilol explicitly warns that "patients should not interrupt or discontinue using Carvedilol Tablet without a physician's advice" and notes that "if you stop taking Carvedilol Tablet suddenly, you could have chest pain and/or a heart attack" 2.
- Take your carvedilol with food on the morning of your procedure
- Acute withdrawal of beta blockers is harmful and increases cardiovascular risk
- The guideline emphasizes that early studies showing harm from perioperative beta blockers may have actually reflected withdrawal effects in patients previously on these medications 1
Angiotensin Receptor Blocker (Losartan) - HOLD
Withhold losartan on the day of your endoscopy. While recent evidence suggests continuing ACE inhibitors/ARBs may be safer than previously thought, the balance of evidence for endoscopic procedures favors holding these medications:
- A 2001 randomized trial demonstrated that patients who continued angiotensin II antagonists experienced significantly more hypotensive episodes during anesthesia (all 19 patients vs 12 of 18 who discontinued), longer duration of hypotension (8±7 min vs 3±4 min), and greater need for vasoconstrictors 3
- The 2024 SPACE trial showed no significant difference in myocardial injury between continuing vs stopping ACE inhibitors/ARBs, but patients who stopped experienced more postoperative hypertension 4
- For lower-risk procedures like endoscopy, the risk-benefit calculation favors avoiding intraoperative hypotension
Key consideration: Intraoperative hypotension from losartan is easily treatable with fluids and vasoconstrictors, but creates unnecessary hemodynamic instability during what is typically a brief, low-risk procedure.
Vasodilator (Hydralazine) - HOLD
Withhold hydralazine on the morning of your procedure. While no specific perioperative guidelines address hydralazine directly, the pharmacology strongly supports holding it:
- Hydralazine is a direct vasodilator that causes significant blood pressure drops, with IV hydralazine producing the most substantial BP reduction among commonly used antihypertensives (13 mmHg mean arterial pressure drop) 5
- The medication is typically used for acute hypertensive episodes, not chronic maintenance
- Combining hydralazine with procedural sedation/anesthesia creates additive hypotensive effects
- Unlike beta blockers, there is no rebound risk from holding hydralazine for one day
Practical Instructions
On the morning of your endoscopy:
- ✓ Take carvedilol with a small amount of water and food
- ✗ Skip losartan
- ✗ Skip hydralazine
Resume all three medications after your procedure once you're eating and drinking normally, typically the same evening or next morning per your usual schedule.
Important caveat: If you have severe heart failure or recent myocardial infarction, discuss this plan with your cardiologist, as the indication for these medications may alter the risk-benefit calculation. However, for routine hypertension management in the context of elective endoscopy, this approach minimizes hemodynamic instability while avoiding harmful beta-blocker withdrawal.