Should telmisartan (angiotensin II receptor antagonist) be continued on the morning of non-emergent surgery?

Perioperative Management of Telmisartan for Non-Emergent Surgery

Telmisartan should be continued up to the morning of non-emergent surgery and restarted promptly in the post-operative period. 1

Rationale for Continuing Telmisartan Perioperatively

• In patients with hypertension, antihypertensive therapy should be continued up to the morning of surgery and restarted promptly in the post-operative period 1
• For patients with grade 1 or 2 hypertension, there is no evidence that delaying surgery to optimize therapy is beneficial 1
• Continuation of angiotensin receptor blockers (ARBs) like telmisartan is reasonable perioperatively 1

Hemodynamic Considerations

• While some evidence suggests that angiotensin II antagonists may increase the risk of hypotensive episodes during anesthesia induction 2, the current guidelines still recommend continuation of therapy
• The potential risks of discontinuing telmisartan include:
  • Rebound hypertension
  • Loss of blood pressure control during the perioperative period 1
  • Increased risk of cardiovascular events 1

Special Considerations

• For patients with grade 3 hypertension (systolic BP ≥180 mmHg and/or diastolic BP ≥110 mmHg), the benefits of delaying surgery to optimize pharmacological therapy should be weighed against the risks of delaying the surgical procedure 1
• If telmisartan is held before surgery for any reason, it is reasonable to restart as soon as clinically feasible postoperatively 1
• Careful monitoring of blood pressure and volume status is essential during the perioperative period 1

Pharmacological Properties of Telmisartan

• Telmisartan has a long elimination half-life, providing effective blood pressure reduction across the entire 24-hour dosage interval 3
• It is highly selective for angiotensin II type 1 receptors 4
• Telmisartan has favorable effects on insulin resistance, lipid levels, left ventricular hypertrophy, and renal function beyond its blood pressure-lowering effects 3

Common Pitfalls to Avoid

• Inadequate communication between surgical and medical teams about the timing of telmisartan administration 5
• Failure to monitor for potential hypotensive episodes during anesthesia induction in patients who have continued telmisartan 2
• Not accounting for potential fluid shifts and volume status changes that may exacerbate the effects of telmisartan in the immediate postoperative period 1

Management Algorithm

1. Continue telmisartan up to the morning of surgery for most patients 1
2. Monitor blood pressure closely during anesthesia induction and have vasopressors readily available 2
3. Ensure adequate volume status perioperatively 1
4. Restart telmisartan promptly in the post-operative period once the patient is hemodynamically stable 1
5. For patients with grade 3 hypertension, consider individual risk-benefit assessment regarding surgery timing 1