From the Guidelines
Losartan should typically be continued on the day of surgery. The most recent and highest quality study, published in 2024, supports the continuation of angiotensin II receptor blockers (ARBs) like losartan up to and including the day of surgery 1. This practice helps maintain blood pressure control during the perioperative period and reduces the risk of rebound hypertension that can occur with sudden discontinuation.
Some key points to consider when deciding whether to continue losartan on the day of surgery include:
- The patient's individual cardiovascular status and risk factors for perioperative hypotension or hypertension
- The type of surgery and potential for significant blood loss or prolonged anesthesia
- The presence of unstable blood pressure, renal dysfunction, or other comorbidities that may impact the decision to continue or hold losartan
According to the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery, antihypertensive agents like losartan can be continued on the day of surgery without excess adverse events 1. However, the decision to continue or hold losartan should ultimately be made by the anesthesiologist and surgical team based on the individual patient's needs and risk factors.
It's also worth noting that previous guidelines, such as the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery, also support the continuation of ARBs like losartan perioperatively 2. Additionally, the 2019 KDOQI US commentary on the 2017 ACC/AHA hypertension guideline suggests that discontinuation of ACE inhibitors or ARBs perioperatively may be considered, but this decision should be made on a case-by-case basis 3.
From the Research
Perioperative Management of Losartan
- The decision to continue or withhold losartan on the day of surgery is not clearly supported by current evidence 4.
- Losartan is an angiotensin II receptor blocker, and its perioperative management is still debated 4.
- Some studies suggest that angiotensin receptor blockers like losartan may have antifibrotic effects, but their use in the perioperative period is not well established 5.
Renin-Angiotensin-Aldosterone System Inhibitors
- The use of renin-angiotensin-aldosterone system inhibitors, including losartan, in the perioperative period is not clearly recommended 4.
- Current evidence supports the perioperative continuation of β-blockers, calcium-channel blockers, and α-2 agonists, but diuretics should be discontinued on the day of surgery 4.
- Losartan has been shown to have renal protective effects in patients with chronic kidney disease 6, 7.
Losartan-Specific Studies
- A study on the dose-related effect of losartan on renal function in patients with chronic heart failure found that high-dose losartan was associated with an increased risk of acute rise in serum creatinine, but also with reduced risk of death or hospitalization for heart failure 6.
- Another study on the efficacy and safety of losartan for hypertrophic cardiomyopathy found that losartan was safe and well-tolerated, but did not significantly reduce left ventricular mass 8.