When to stop antihypertensive (antihypertensive) treatment (ATT)?

When to Stop Antihypertensive Treatment

Antihypertensive therapy should generally be continued long-term in most patients with hypertension, as stopping treatment leads to loss of cardiovascular protection and increased risk of myocardial infarction, stroke, and heart failure. 1 However, specific clinical scenarios warrant discontinuation or down-titration.

Clinical Scenarios Warranting Discontinuation

White Coat Hypertension

• When home blood pressure monitoring consistently shows diastolic BP <80 mm Hg, antihypertensive medications can be withdrawn. 2
• In one protocol-driven study, 25.6% of patients permanently stopped treatment when self-measured BP revealed diastolic readings consistently <80 mm Hg, though only 64.7% maintained adequate control (diastolic BP <85 mm Hg) after discontinuation. 2
• This indicates that careful monitoring is essential after stopping therapy, as many patients will require reinitiation of treatment.

Symptomatic Hypotension in Heart Failure

In patients with heart failure with reduced ejection fraction (HFrEF) experiencing symptomatic low BP, a structured down-titration algorithm should be followed rather than complete cessation. 2

The 2025 European Heart Failure Association provides a specific hierarchy for medication reduction: 2

For patients with eGFR <30 ml/min/1.73 m²:

• First reduce or stop RAS inhibitors (ACE inhibitors/ARBs/ARNIs)
• Then reduce MRA (mineralocorticoid receptor antagonists)

For patients with potassium >5.0 mEq/L:

• First reduce MRA
• Then reduce beta-blockers

For patients with heart rate <60 bpm:

• First stop ivabradine
• Then decrease RAS inhibitors
• Consider cardiac pacing (CRT) if appropriate

For patients with heart rate >70 bpm:

• First decrease ACE inhibitor/ARB/ARNI
• Then decrease RAS inhibitors

Acute Stroke Management

In acute ischemic stroke, pre-existing antihypertensive medications should be temporarily discontinued or reduced during the acute phase (first 24 hours). 2

• Antihypertensive therapy can be restarted after the initial 24 hours from stroke onset in most patients. 2
• This temporary cessation prevents hypoperfusion to ischemic brain tissue where autoregulation is impaired.

Post-Bevacizumab Therapy

Hypertension induced by bevacizumab typically resolves after treatment completion, warranting medication reassessment. 2

• Follow-up should occur within 4 weeks of stopping bevacizumab to reassess BP and plan for reducing or stopping antihypertensive treatment. 2
• Once BP returns to normal, annual monitoring is recommended. 2

Critical Warnings About Abrupt Discontinuation

Drug-Specific Withdrawal Syndromes

Beta-blockers pose the highest risk and should NEVER be stopped abruptly: 2, 1

• Rebound tachycardia, severe hypertension, and precipitation of angina or myocardial infarction can occur. 1
• Abrupt withdrawal can lead to clinical deterioration in heart failure patients. 2
• If discontinuation is necessary, taper gradually over 1-2 weeks minimum.

Clonidine and central alpha-agonists cause dangerous rebound hypertension: 1

• Symptoms include severe headache, agitation, and tremor within 24-72 hours of cessation. 1
• These require the most cautious tapering approach.

ACE inhibitors/ARBs have fewer acute withdrawal symptoms but lead to gradual BP elevation and loss of cardiovascular protection. 1

Calcium channel blockers can cause reflex tachycardia and BP elevation if discontinued rapidly. 1

Patients at Highest Risk from Discontinuation

Do NOT stop antihypertensive therapy in: 1

• Patients with severe baseline hypertension (SBP ≥180 mm Hg or DBP ≥110 mm Hg)
• Elderly patients with longer duration of hypertension
• Patients with pre-existing cardiovascular disease
• Pregnant women (requires careful specialist management)

Monitoring After Discontinuation

When discontinuation is appropriate, implement structured follow-up: 2

• Reassess BP within 2-4 weeks of stopping medication
• Use home BP monitoring to detect white coat effect versus true hypertension 2
• Have a contingency plan for medication reinitiation if BP rises
• Monitor annually even after successful discontinuation 2

Common Pitfalls to Avoid

• Never stop medications without patient education about withdrawal symptoms and when to seek help. 1
• Avoid stopping all medications simultaneously - taper one at a time if multiple agents are being discontinued. 2
• Do not discontinue therapy based solely on office BP readings - confirm with home monitoring to rule out white coat hypertension. 2
• Never abruptly stop beta-blockers or clonidine - these require gradual tapering. 2, 1

When Continuation is Mandatory

Continue antihypertensive therapy in: 3

• Patients with persistent SBP ≥130 mm Hg or DBP ≥80 mm Hg on home monitoring
• Patients with high atherosclerotic CVD risk regardless of BP level
• Perioperative period for most patients 1
• Patients with target organ damage (cardiac, renal, cerebrovascular)

The default position should be continuation of therapy, as only 44% of US adults with hypertension achieve adequate BP control, and stopping treatment increases cardiovascular risk by 20-30%. 3, 1