From the Guidelines
Sacubitril/valsartan should be held for at least 24 hours before elective surgery. This medication, which combines an angiotensin receptor blocker (valsartan) with a neprilysin inhibitor (sacubitril), can potentially cause hypotension during surgery and may interact with anesthesia. The primary concern is that it can lead to prolonged hypotension under anesthesia due to its blood pressure-lowering effects. For emergency surgeries, the anesthesiologist should be informed about the patient's use of this medication so they can manage potential hypotension appropriately.
After surgery, sacubitril/valsartan can typically be resumed once the patient is hemodynamically stable, usually within 24-48 hours post-operation, and able to take oral medications. The decision to restart should be based on the patient's blood pressure, kidney function, and overall clinical status. This recommendation aligns with the general approach for other renin-angiotensin system inhibitors like ACE inhibitors and ARBs, as sacubitril/valsartan affects similar physiological pathways that regulate blood pressure and fluid balance, as suggested by guidelines such as those from the American College of Cardiology/American Heart Association 1.
Some key points to consider include:
- The risk of hypotension is a significant concern with the use of sacubitril/valsartan in the perioperative period, similar to ACE inhibitors and ARBs 1.
- The management of antithrombotic therapy and the use of medications like ASA in the perioperative period should also be considered, although the primary concern with sacubitril/valsartan is its potential to cause hypotension rather than its effects on thrombosis 1.
- The decision to hold or continue sacubitril/valsartan should be made on a case-by-case basis, taking into account the patient's individual risk factors and the type of surgery being performed, with the goal of minimizing morbidity, mortality, and improving quality of life.
From the Research
Sacubitril/Valsartan and Surgery
- There is no direct evidence in the provided studies that specifically addresses whether sacubitril/valsartan should be held before surgery 2, 3, 4, 5, 6.
- The studies primarily focus on the benefits, usage, and effects of sacubitril/valsartan in patients with heart failure, particularly those with reduced ejection fraction.
- However, it is known that angiotensin receptor-neprilysin inhibitors like sacubitril/valsartan can affect blood pressure and renal function, which might be relevant considerations in the perioperative period 3, 5, 6.
- In general clinical practice, the decision to hold or continue any medication before surgery depends on various factors, including the type of surgery, the patient's medical condition, and the potential risks and benefits of continuing or withholding the medication.
- For sacubitril/valsartan, as with other heart failure medications, the decision would likely be made on a case-by-case basis, considering the patient's heart failure status, renal function, and overall health condition, as well as the nature of the surgical procedure 4.
Considerations for Holding Sacubitril/Valsartan
- The potential for hypotension: Sacubitril/valsartan can lower blood pressure, which might be a concern during surgery when blood pressure management is critical 3.
- Renal function: Since sacubitril/valsartan can affect renal function, patients undergoing surgery might need close monitoring, especially if they have pre-existing renal impairment 5, 6.
- Interaction with anesthesia: Although not directly addressed in the provided studies, the potential interaction between sacubitril/valsartan and anesthetic agents could be a consideration.
Recommendations
- Given the lack of direct evidence, recommendations would be based on general principles of perioperative management of patients on sacubitril/valsartan.
- It is essential to consult with a cardiologist or the patient's primary care physician to make an informed decision about managing sacubitril/valsartan in the perioperative period 2, 4.
- Close monitoring of blood pressure, renal function, and overall cardiac status is crucial for patients on sacubitril/valsartan undergoing surgery 5, 6.