From the Guidelines
Losartan should typically be continued up to the day of surgery, but it is reasonable to skip the dose on the morning of the procedure to minimize the risk of intraoperative hypotension. For most non-cardiac surgeries, taking the regular dose of losartan on the day before surgery is recommended. After surgery, losartan can usually be resumed once the patient is stable and taking oral medications again 1. However, this recommendation may vary based on the patient's specific situation, such as severe heart failure or uncontrolled hypertension, which might require continuation of losartan even on the morning of surgery. Losartan works by blocking angiotensin II receptors, relaxing blood vessels, and lowering blood pressure. During anesthesia, this effect can sometimes compound with anesthesia-induced vasodilation, potentially causing excessive blood pressure drops. Always discuss the losartan regimen with both the surgeon and the physician who prescribed it at least a week before surgery to receive personalized instructions based on the patient's medical history, the type of surgery, and their cardiovascular risk factors. Some studies suggest that discontinuation of ACE inhibitors or ARBs perioperatively may be considered 1, but the decision should be made on a case-by-case basis, prioritizing the patient's safety and well-being. It is essential to weigh the potential benefits of delaying surgery to optimize the effects of antihypertensive medications against the risk of delaying the surgical procedure 1. Ultimately, the goal is to balance blood pressure control while minimizing the risk of intraoperative hypotension and ensuring the best possible outcome for the patient.
From the Research
Losartan and Surgery
- Losartan is an angiotensin receptor blocker (ARB) commonly used to manage hypertension and heart disease.
- The decision to continue or withhold losartan before surgery depends on various factors, including the type of surgery, patient's medical history, and current clinical guidelines.
Perioperative Management of ARBs
- A study published in 2010 2 suggested that continuing angiotensin converting enzyme (ACE) inhibitors and ARBs, such as losartan, increases the likelihood of intraoperative hypotension.
- However, a systematic review published in 2018 3 found that withholding ACE-I/ARB therapy was not associated with a difference in mortality or major cardiac events, but was associated with significantly less intraoperative hypotension.
- Another study published in 2017 4 discussed the perioperative management of antihypertensive medications, including ARBs, and found that there is no clear recommendation on the continuation of renin-angiotensin-aldosterone system inhibitors, such as losartan, in the perioperative period.
Anesthetic Considerations
- A study published in 2013 5 discussed the management of perioperative hypertension and hypotension in oral surgery, and suggested that hypotension can be managed by decreasing the depth of anesthesia, intravenous fluids, and vasopressors.
- Another study published in 1985 6 discussed the anesthetic implications of calcium channel blockers, and suggested that monitoring of cardiovascular and neuromuscular functions is essential when using these medications in patients undergoing anesthesia.
Recommendations
- Based on the available evidence, it is recommended that patients taking losartan should consult with their physician or anesthesiologist to determine the best course of action regarding continuation or withholding of the medication before surgery 2, 3, 4.
- The decision to continue or withhold losartan should be made on a case-by-case basis, taking into account the individual patient's medical history, the type of surgery, and current clinical guidelines.