What medications should be continued or held preoperatively?

Perioperative Medication Management: Continue vs. Hold

Most antihypertensive medications should be continued perioperatively, with the notable exception that ACE inhibitors and ARBs may be held on the day of surgery, while beta blockers and clonidine must never be stopped abruptly due to risk of rebound hypertension and myocardial ischemia. 1

Medications That MUST Be Continued

Beta Blockers

• Continue through surgery without interruption in patients already taking them chronically 1
• Abrupt preoperative discontinuation is potentially harmful and can cause rebound hypertension and coronary ischemia 1
• Never start beta blockers on the day of surgery in beta blocker-naive patients 1
• Can be given intravenously if patient cannot take oral medications postoperatively 1

Clonidine

• Must be continued perioperatively to avoid rebound blood pressure elevations that can precipitate coronary ischemia 1
• Can be administered transcutaneously in cases of postoperative ileus 1
• Abrupt preoperative discontinuation is potentially harmful 1

Statins

• Continue long-term statin therapy perioperatively 2
• Should be started in patients with clinical indications who are not already receiving statins 2

Tricyclic Antidepressants

• Continue perioperatively as withdrawal risks outweigh surgical concerns 3
• Monitor for enhanced responses to anesthetic agents due to norepinephrine potentiation 3
• Watch for serotonin syndrome when combined with certain opioids 3

Bisphosphonates

• Continue without interruption as they pose no documented surgical complications 4
• Do not impair surgical healing 4
• Stopping may worsen bone health in at-risk patients 4

Omega-3 Supplements

• Continue until surgery as they do not increase perioperative bleeding risk 5
• May provide anti-inflammatory benefits that support recovery 5

Medications to Consider Holding

ACE Inhibitors and ARBs

• Discontinuation perioperatively may be considered based on increased risk of acute kidney injury with hemodynamic challenges 1
• Can be continued if patients are hemodynamically stable with good renal function and normal electrolytes 2
• This recommendation is not supported by level 1 evidence 1

Antiplatelet Agents: Risk-Stratified Approach

For Primary Prevention:

• Discontinue aspirin 7-10 days before surgery unless the risk of major adverse cardiac event exceeds bleeding risk 2

For Secondary Prevention (established cardiovascular disease):

• Continue aspirin perioperatively except for procedures with very high bleeding risk 2, 6, 7
• Bleeding in closed spaces (intracranial surgery, spinal surgery in medullary canal, posterior chamber eye surgery) is the main exception 6

Clopidogrel Management:

• Continue if prescribed for acute coronary syndrome or during stent re-endothelialization 6
• When possible, interrupt therapy 5 days prior to surgery with major bleeding risk 8
• Resume as soon as hemostasis is achieved 8

Critical Timing After Percutaneous Coronary Intervention:

• Delay surgery if possible for at least 14 days after PCI without stent 2
• Delay 30 days after bare-metal stent placement 2
• Delay 6-12 months after drug-eluting stent placement 2
• Premature withdrawal of antiplatelet agents after stent placement carries a 10% risk of vascular events and potentially fatal stent thrombosis 9

Dietary Supplements with Bleeding Risk

Hold for 2 weeks before surgery: 1

• Aloe, arnica, boldo, bromelain, cat's claw, danshen, devil's claw, dong quai, evodia, fenugreek, feverfew, garlic, ginger, ginkgo, ginseng (all types), guarana, horse chestnut, policosanol, resveratrol, saw palmetto, turmeric, vanadium, vitamin E

Hold for 24 hours before surgery: 1

• 5-hydroxytryptophan, L-tryptophan, S-adenosylmethionine (due to rapid metabolism)

Hold for 2 weeks and consider weaning: 1

• St. John's wort (induces CYP3A4, multiple drug interactions)
• Caffeine supplements and kola nut (taper to avoid withdrawal)

Surgery Deferral Considerations

Consider deferring elective surgery if: 1

• Systolic BP ≥180 mm Hg or diastolic BP ≥110 mm Hg before day of surgery
• Patient has cardiovascular risk factors for perioperative complications
• Recent history of poorly controlled hypertension

Common Pitfalls to Avoid

1. Never confuse bisphosphonates with medications requiring discontinuation (anticoagulants, antiplatelet agents) 4
2. Do not substitute heparin or LMWH for antiplatelet therapy - this does not protect against coronary artery or stent thrombosis 6
3. Avoid tight BP control on day of surgery - maintaining SBP >90 mm Hg or MAP ≥60-65 mm Hg is the target to reduce myocardial injury 1
4. Do not stop medications abruptly - beta blockers and clonidine require continuation or gradual weaning 1