Perioperative Management of Telmisartan and HCTZ
Telmisartan (an angiotensin II receptor blocker) and hydrochlorothiazide (HCTZ) should be temporarily discontinued before surgery to reduce the risk of intraoperative hypotension and hemodynamic instability.
Rationale for Holding Telmisartan (ARB)
- Perioperative use of angiotensin receptor blockers like telmisartan carries a significant risk of severe hypotension during anesthesia, particularly following induction 1
- ARBs can impair the response to vasopressors, making it more difficult to manage intraoperative hypotension when it occurs 1
- Studies show that patients receiving ARBs on the morning of surgery experience more frequent and prolonged episodes of hypotension requiring vasopressor treatment compared to those who discontinued ARBs the day before surgery 2
- The European Society of Cardiology guidelines recommend that transient discontinuation of ACE inhibitors and ARBs before non-cardiac surgery should be considered in hypertensive patients 1
Timing of Telmisartan Discontinuation
- Telmisartan should be discontinued 24 hours before surgery when prescribed for hypertension 1
- This timing allows for reduction in the risk of severe intraoperative hypotension while minimizing the risk of rebound hypertension 1
- Telmisartan should be resumed after surgery as soon as the patient's volume status is stable to maintain blood pressure control 1
Rationale for Holding HCTZ (Diuretic)
- The European Society of Cardiology guidelines explicitly recommend that hypertensive patients discontinue low-dose diuretics on the day of surgery 1
- Diuretics can cause volume depletion and electrolyte disturbances, which may increase the risk of perioperative hypotension and arrhythmias 1
- Hypokalaemia from diuretics is reported in up to 34% of patients undergoing surgery and is associated with increased risk of ventricular arrhythmias and perioperative mortality 1
- Current evidence supports discontinuing diuretics on the day of surgery and resuming them in the postoperative period 3
Special Considerations
- In patients with heart failure, diuretics should be continued up to the day of surgery, resumed intravenously perioperatively, and continued orally when possible 1
- Electrolyte disturbances (especially hypokalemia and hypomagnesemia) should be corrected before surgery 1
- For patients with stable left ventricular systolic dysfunction, it may be reasonable to continue ACE inhibitors/ARBs during the perioperative period under close monitoring 1
Resuming Medications Postoperatively
- Both telmisartan and HCTZ should be resumed orally as soon as clinically possible after surgery 1
- Delaying the resumption of preoperative ACE inhibitors/ARBs has been associated with increased 30-day mortality risk 1
- Monitoring of blood pressure, volume status, and renal function is essential when restarting these medications 1
Potential Risks of Discontinuation
- Rebound hypertension is a potential risk when discontinuing ARBs like telmisartan 4
- However, this risk is outweighed by the greater risk of severe intraoperative hypotension if these medications are continued 2
- The short-term discontinuation of these medications for surgery does not significantly impact long-term blood pressure control or cardiovascular outcomes 5