Do you hold antihypertensive medications in patients with GI (Gastrointestinal) bleeding who have stable and normotensive systolic blood pressure (SBP)?

Management of Antihypertensive Medications During GI Bleeding

Antihypertensive medications should be continued in patients with GI bleeding who have stable and normotensive blood pressure, as discontinuation may increase cardiovascular risk without providing significant benefit.

Risk Assessment and Decision-Making Algorithm

Factors Supporting Continuation of Antihypertensives:

• Stable hemodynamics (normotensive SBP)
• Patients with established cardiovascular disease
• Patients with high cardiovascular risk profiles
• Patients on antihypertensives for secondary prevention

Factors That May Warrant Temporary Adjustment:

• Active hemodynamic instability (hypotension)
• Acute kidney injury
• Severe volume depletion

Evidence-Based Rationale

The European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy highlights that antihypertensive medications generally should be continued in patients with stable blood pressure, even during bleeding events 1. Discontinuation of cardiovascular medications during acute illness is associated with increased mortality and adverse cardiovascular outcomes.

The risk-benefit analysis strongly favors continuation of antihypertensives when blood pressure is stable and normotensive because:

1. Abrupt discontinuation of antihypertensive therapy may lead to rebound hypertension
2. Patients with GI bleeding often have underlying cardiovascular comorbidities that require ongoing management
3. The European Heart Journal guidelines emphasize that maintaining cardiovascular medications is critical for secondary prevention 1

Special Considerations for Different Antihypertensive Classes

ACE Inhibitors/ARBs:

• Continue if renal function is stable
• Monitor creatinine and potassium if significant volume depletion occurs

Beta-Blockers:

• Particularly important to continue in patients with coronary artery disease or heart failure
• Abrupt discontinuation can precipitate tachycardia and worsen myocardial oxygen demand

Calcium Channel Blockers:

• Generally safe to continue
• No evidence of increased GI bleeding risk with these agents 2

Diuretics:

• May require temporary dose adjustment if significant volume depletion
• Consider holding only if there are signs of pre-renal azotemia

Concomitant Antiplatelet/Anticoagulant Management

For patients on dual therapy (antihypertensives plus antiplatelets):

• If the patient is on aspirin for secondary prevention, the Asian Pacific Association of Gastroenterology recommends continuing aspirin even during acute GI bleeding 1
• Consider adding a proton pump inhibitor for GI protection, particularly in patients with risk factors for GI bleeding 3
• For patients on dual antiplatelet therapy, consider temporarily withholding the P2Y12 inhibitor while continuing aspirin 1

Common Pitfalls to Avoid

1. Unnecessary discontinuation: Holding antihypertensives in normotensive patients with stable GI bleeding can lead to cardiovascular complications without improving bleeding outcomes.

2. Failure to reassess: Blood pressure and volume status should be regularly monitored during active GI bleeding, with medication adjustments made accordingly.

3. Overlooking medication interactions: When adding medications to manage GI bleeding (such as PPIs), consider potential interactions with existing cardiovascular medications.

4. Delayed resumption: If antihypertensives are temporarily held due to hypotension, they should be promptly resumed once hemodynamic stability is achieved.

By following this approach, clinicians can optimize cardiovascular protection while safely managing patients with GI bleeding who have stable blood pressure.