Consequences of Stopping Antihypertensive Medications
Abruptly stopping antihypertensive medications can lead to dangerous rebound hypertension, increased risk of cardiovascular events, and potentially life-threatening complications, especially with certain drug classes like beta-blockers and central alpha-agonists. 1
Immediate Drug-Specific Withdrawal Effects
Beta-blockers: Can cause rebound tachycardia, increased blood pressure, and potentially precipitate angina or myocardial infarction in patients with underlying coronary artery disease 1
Clonidine and central alpha-agonists: May cause dangerous rebound hypertension with headache, agitation, and tremor within 24-72 hours of discontinuation 1, 2
ACE inhibitors/ARBs: Generally have fewer acute withdrawal symptoms but lead to gradual blood pressure elevation 1
Calcium channel blockers: Can cause reflex tachycardia and blood pressure elevation if discontinued rapidly 1, 3
Short-acting dihydropyridines: Cause intermittent BP control at each dosing, particularly at higher doses, leading to sympathetic activation 3
Long-Term Consequences
Loss of cardiovascular protection increases the risk of myocardial infarction, stroke, and heart failure 1
Increased risk of cardiovascular events occurs, especially in patients with pre-existing cardiovascular disease 1, 2
Potential accelerated target organ damage, including cardiac, renal, and cerebrovascular complications 1
Blood pressure typically rises after discontinuation (systolic by approximately 9.75 mmHg and diastolic by 3.5 mmHg) 4
Risk Factors for Severe Withdrawal Reactions
Severe baseline hypertension (SBP ≥180 mmHg or DBP ≥110 mmHg) 1, 2
Presence of ischemic heart disease 2
Renovascular or high-renin hypertension 2
Use of high doses of multiple antihypertensive drugs 2
Older age and longer duration of hypertension 1
Special Populations Considerations
Perioperative patients: Antihypertensive therapy should be continued throughout the perioperative period for most patients 1
Pregnant women: Careful management of antihypertensive discontinuation is critical, as severe hypertension increases risks to both mother and fetus 1, 5
Elderly patients: More sensitive to abrupt blood pressure changes and at higher risk for falls and orthostatic hypotension during medication adjustments 1, 4
Safer Approaches to Discontinuation (When Medically Necessary)
Gradual tapering of antihypertensive medications over seven to ten days will prevent symptoms and marked elevation of blood pressure 2
Temporary discontinuation for diagnostic evaluation can be done safely in controlled settings with appropriate monitoring protocols 6
Candidates who may successfully discontinue therapy with lower risk include those with mild essential hypertension who are young, have normal body weight, low salt intake, no alcohol consumption, low pretreatment blood pressure, successful therapy with one drug only, and minimal target organ damage 7
When Discontinuation Symptoms Occur
Re-administration of the previously discontinued drug is the most appropriate treatment for withdrawal syndrome 2
62% of patients in controlled settings report no complaints during temporary discontinuation, 24% experience mild discomfort, and 14% require escape medication 6
Monitor for symptoms of enhanced sympathetic activity, severe hypertension, and ischemic cardiovascular events 2