Should ARBs Be Taken on the Day of Surgery for Persistently Elevated Blood Pressure?
No, ARBs should be discontinued 24 hours before surgery even in patients with persistently elevated blood pressure, as the risk of intraoperative hypotension and associated complications outweighs the short-term risk of elevated blood pressure. 1, 2
Guideline-Based Recommendation
The ACC/AHA guidelines explicitly state that recent cohort evidence demonstrates patients who stopped ARBs 24 hours before noncardiac surgery had lower rates of death, stroke, myocardial injury, and intraoperative hypotension compared to those continuing these medications until surgery. 3, 2 This represents the most current evidence-based approach to ARB management in the perioperative setting.
Management Algorithm for Elevated BP Without ARBs
Preoperative Blood Pressure Thresholds
- If BP ≥180/110 mmHg: Consider deferring elective major surgery until better control is achieved. 3, 1
- Target BP <130/80 mmHg: This is reasonable before undertaking major elective procedures, though this should be achieved with medications other than ARBs in the immediate preoperative period. 3, 1
Alternative Medications to Continue
- Beta blockers: Must be continued if the patient is already taking them chronically to avoid rebound hypertension—abrupt discontinuation is potentially harmful. 3, 1
- Calcium channel blockers: Should be continued through the day of surgery as they do not cause significant intraoperative hypotension. 2
- Alpha-2 agonists (clonidine): Must be continued to avoid rebound hypertension. 3
Intraoperative Management
If hypertension develops intraoperatively after ARBs have been held, use IV antihypertensive agents such as:
- Clevidipine
- Esmolol
- Nicardipine
These should be administered until oral medications can be resumed postoperatively. 3, 1
Critical Pitfalls to Avoid
Do not continue ARBs on the day of surgery even with elevated BP, as the risk of severe intraoperative hypotension (particularly during induction and with concomitant beta-blocker use) creates greater morbidity risk than short-term hypertension. 2
Do not abruptly stop beta blockers or clonidine if the patient is taking them—this creates rebound hypertension that is more dangerous than the controlled discontinuation of ARBs. 3, 1
Postoperative Restart Protocol
- Restart ARBs once the patient is hemodynamically stable and volume status is adequate. 2
- Monitor blood pressure closely after restarting to prevent postoperative hypotension. 2
- Resume as soon as clinically feasible when oral intake is tolerated. 2
Special Consideration
For patients with left ventricular systolic dysfunction, there is nuanced guidance suggesting ARBs may be continued under close monitoring, but this represents a specific exception requiring individualized hemodynamic monitoring rather than routine practice. 2