From the Guidelines
Antihypertensive medications should be restarted as soon as clinically feasible postoperatively, ideally within 24-48 hours, to minimize the risk of postoperative hypertensive complications and maintain optimal organ perfusion. This recommendation is based on the most recent and highest quality evidence from the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1, 2, 3. The guideline suggests that continuation of angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) perioperatively is reasonable, and if held before surgery, it is reasonable to restart as soon as clinically feasible postoperatively.
When deciding to restart antihypertensive medications, consider the patient's:
- Hemodynamic stability
- Ability to take oral medications
- Presence of contraindications such as hypotension or acute kidney injury The following medications can be restarted as follows:
- Beta-blockers (like metoprolol, carvedilol): within 24 hours if possible to avoid rebound hypertension
- ACE inhibitors and ARBs (like lisinopril, losartan): may be delayed 48-72 hours if there are concerns about postoperative hypotension or renal function
- Calcium channel blockers (amlodipine, diltiazem) and diuretics: can typically be restarted once oral intake is established For patients who cannot take oral medications, consider IV alternatives like labetalol, hydralazine, or nicardipine until oral administration is possible. Monitor blood pressure closely during the transition, aiming for a target below 140/90 mmHg for most patients, with potentially higher targets (150/90 mmHg) for elderly patients. Early reinitiation of antihypertensives helps prevent postoperative hypertensive complications, including myocardial ischemia, stroke, and bleeding, while maintaining appropriate organ perfusion during the recovery period 3.
From the Research
Antihypertensive Medication Management Post-Operatively
- The decision to restart antihypertensive medications post-operatively depends on various factors, including the type of surgery, patient's medical history, and current clinical condition 4.
- There is no clear recommendation on when to restart antihypertensive medications post-operatively, but it is generally agreed that medications should be individualized for each patient 5, 4.
- Some studies suggest that antihypertensive medications can be discontinued in patients who have undergone certain types of surgery, such as bariatric surgery, and that the need for these medications may decrease post-operatively 6.
- The timing of resumption of beta-blockers after discontinuation of vasopressors is not associated with post-operative atrial fibrillation in critically ill patients recovering from non-cardiac surgery 7.
- Postoperative hypotension is associated with adverse clinical outcomes, including major adverse cardiac or cerebrovascular events, but the association between postoperative hypotension and outcomes in patients without intraoperative hypotension is not well understood 8.
Considerations for Restarting Antihypertensive Medications
- The type of antihypertensive medication and its potential interactions with other medications should be considered when deciding when to restart medications post-operatively 4.
- Patients who were taking antihypertensive medications pre-operatively may require adjustments to their medication regimen post-operatively, depending on their clinical condition and response to treatment 5, 4.
- The use of diuretics, for example, should be discontinued on the day of surgery and resumed in the postoperative period, while beta-blockers, calcium-channel blockers, and α-2 agonists can be continued perioperatively 4.
- The management of antihypertensive medications post-operatively should be individualized for each patient, taking into account their medical history, current clinical condition, and potential interactions with other medications 5, 4.