Resumption of Antihypertensive Medications After Cystoscopy
Antihypertensive medications should be resumed as soon as the patient is clinically stable and able to take oral medications after cystoscopy, typically within 24 hours of the procedure, unless the patient is hypotensive or has acute kidney injury.
General Principles for Postoperative Antihypertensive Resumption
The Perioperative Quality Initiative provides clear guidance that home antihypertensive medications should be restarted as soon as appropriate in the clinical context 1. For routine outpatient procedures like cystoscopy, this typically means resumption can occur on the same day or the following morning.
Class-Specific Timing Recommendations
Beta-blockers should be continued in the postoperative period with specific criteria for withholding only to avoid hypotension (systolic BP <90 mmHg) and bradycardia (heart rate <60 bpm) 1. There is evidence of harm from withholding beta-blockers postoperatively 1.
ACE inhibitors and ARBs should be resumed within 48 hours after surgery unless the patient has persistent hypotension or acute kidney injury 1. Given that cystoscopy is a minimally invasive procedure with low risk of significant hemodynamic instability, these can typically be resumed the next morning if blood pressure is stable.
Alpha-agonists (such as clonidine) can cause withdrawal hypertension, so these should be resumed after beta-blockers and ACE inhibitors/ARBs if the patient is normotensive 1.
Calcium channel blockers should be resumed after the patient is on home doses of beta-blockers and ACE inhibitors/ARBs, though there is no direct evidence about specific timing 1.
Diuretics should be resumed based on the patient's volume status and the indication for the diuretic 1. After cystoscopy, assess for adequate oral intake and absence of orthostatic hypotension before resuming.
Clinical Assessment Before Resumption
Before restarting any antihypertensive medication, confirm the following 1:
- Blood pressure stability: Systolic BP >90-100 mmHg without signs of hypotension
- Heart rate: >60 bpm if resuming beta-blockers
- Volume status: Adequate oral intake, no significant bleeding or hematuria requiring intervention
- Renal function: No acute kidney injury if resuming ACE inhibitors/ARBs
- Absence of orthostatic symptoms: Patient can ambulate without dizziness
Cystoscopy-Specific Considerations
Cystoscopy is generally well-tolerated with minor complications 2. The most common post-procedure issues are hematuria, dysuria, and bladder discomfort, which typically resolve within 2-3 days 3. These symptoms do not contraindicate antihypertensive resumption unless there is:
- Massive hematuria requiring intervention (rare but reported) 4
- Hemodynamic instability from bleeding
- Inability to take oral medications due to nausea or sedation
Common Pitfalls to Avoid
Do not unnecessarily delay resumption beyond 24-48 hours, as prolonged discontinuation increases cardiovascular risk, particularly in patients on antihypertensives for secondary prevention of stroke or myocardial infarction 1.
Do not withhold all antihypertensives simultaneously if blood pressure is mildly elevated postoperatively. Resume medications sequentially based on the class-specific algorithm above 1.
Do not resume medications if the patient is hypotensive (systolic BP <90 mmHg) or has signs of volume depletion from inadequate oral intake or ongoing hematuria 1.
Practical Algorithm for Same-Day Cystoscopy
- Day of procedure: Hold morning antihypertensives if instructed preoperatively
- Post-procedure (2-4 hours): If vital signs stable, patient tolerating oral intake, and no significant hematuria, resume beta-blockers
- Evening of procedure or next morning: Resume ACE inhibitors/ARBs if BP >100/60 mmHg and no AKI
- Next 24-48 hours: Resume alpha-agonists, calcium channel blockers, and diuretics based on BP and volume status
All antihypertensive medications should be omitted if the patient becomes hypotensive at any point 1.