Is continuation of antihypertensive medication, antiplatelet therapy, and a statin medically indicated for a patient with a history of hypertension, presenting with numbness, headache, and blurry vision, after sinus stenting procedures?

Post-Venous Sinus Stenting Medical Management

Yes, continuation of antihypertensive medication, antiplatelet therapy, and statin is medically indicated and essential following venous sinus stenting procedures in this patient with hypertension and neurological symptoms.

Antiplatelet Therapy Post-Stenting

Antiplatelet agents must be administered prior to stenting and continued for at least 3-6 months following venous sinus stent placement 1. This represents a strong recommendation based on venous sinus stenting literature, as thrombosis of the stent poses significant risk for recurrent symptoms and neurological deterioration 1.

• Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is the standard approach, mirroring protocols used in other vascular stenting procedures 1
• The minimum duration of 3-6 months is critical for endothelialization of the stent 1
• Beyond 6 months, continuation should be guided by individual thrombotic risk assessment and bleeding risk 1

Antihypertensive Management

Antihypertensive medications should be restarted as soon as clinically reasonable postoperatively to avoid complications from postoperative hypertension 1. This is a Class I recommendation from the 2024 AHA/ACC perioperative guidelines.

Blood Pressure Targets Post-Procedure

• Maintain mean arterial pressure (MAP) ≥60-65 mm Hg or systolic blood pressure (SBP) ≥90 mm Hg to reduce risk of myocardial injury and end-organ damage 1
• Treat hypotension aggressively in the immediate postoperative period to limit cardiovascular, cerebrovascular, and renal events 1
• For patients with chronic hypertension like this 51-year-old, continuing baseline antihypertensive regimen prevents rebound hypertension 1

Specific Considerations

• Beta blockers and clonidine: If the patient was on these agents preoperatively, they must be continued to avoid rebound hypertension, which can be particularly harmful post-neurovascular procedures 1
• ACE inhibitors/ARBs: While perioperative discontinuation may be considered during some surgeries due to intraoperative hypotension risk, they should be resumed postoperatively once hemodynamic stability is confirmed 1
• Resume oral antihypertensives when oral intake is tolerated, typically within 24-48 hours 1

Statin Therapy

Statin therapy should be continued in this patient based on multiple considerations:

• Prior statin use is associated with better functional outcomes following ischemic neurological events (46.3% good outcome vs 36.7% in non-users, absolute risk difference 9.6%) 2
• Statins provide pleiotropic vascular protective effects beyond lipid lowering, including endothelial stabilization and anti-inflammatory properties 2
• Given the patient's hypertension and neurological symptoms (left-sided numbness, headache, blurry vision), he has established cardiovascular risk factors warranting statin therapy 1

Post-Stenting Surveillance Requirements

Patients require close monitoring for recurrent symptoms that may indicate stent complications 1:

• In-stent stenosis occurs in 3.4% of patients 3
• Stent-adjacent stenosis develops in 11.4% of cases 3
• If symptoms recur after initial resolution, repeat angiography and manometry must be performed to evaluate for recurrent stenosis 1. This is a strong recommendation from venous sinus stenting guidelines.

Expected Outcomes

With appropriate medical management, clinical improvement rates are:

• Headache: 78.3% 3
• Papilledema: 94.4% 3
• Visual symptoms: 86.5% 3

Critical Pitfalls to Avoid

• Never abruptly discontinue antiplatelet therapy within the first 3-6 months post-stenting, as this dramatically increases thrombosis risk 1
• Do not stop beta blockers or clonidine abruptly if the patient was on these preoperatively, as rebound hypertension can precipitate neurological deterioration 1
• Avoid excessive blood pressure lowering in the immediate postoperative period; hypotension (MAP <60-65 mm Hg) increases risk of stroke, myocardial injury, and acute kidney injury 1
• Monitor for bleeding complications given DAPT, particularly epistaxis or gastrointestinal bleeding, which occurred in case reports of patients on dual antiplatelet therapy 1

Monitoring Schedule

• Blood pressure monitoring: Daily initially, then weekly until stable 1
• Neurological symptom assessment: Any recurrence of headache, visual changes, or papilledema warrants urgent evaluation 1
• Platelet function: Not routinely required, but consider if bleeding complications arise 1
• Repeat imaging: Only if symptoms recur after initial improvement 1