When to withhold antihypertensive medication?

From the Guidelines

Antihypertensive medications should be held in patients with acute ischemic stroke unless the diastolic blood pressure is >120 mm Hg or the systolic blood pressure is >220 mm Hg, as aggressive treatment of elevated blood pressure could be detrimental due to secondary reduction of perfusion in the area of ischemia 1. When considering holding anti-hypertensive medication, it's crucial to weigh the risks and benefits, particularly in the context of acute ischemic stroke. The primary concern is the potential for reducing perfusion in the ischemic area, which could exacerbate the infarction.

• Key factors to consider when deciding to hold anti-hypertensive medication include:
  • Blood pressure levels: holding medication is generally recommended unless diastolic blood pressure exceeds 120 mm Hg or systolic blood pressure exceeds 220 mm Hg 1.
  • Presence of other end-organ involvement: conditions such as aortic dissection, acute myocardial infarction, pulmonary edema, or hypertensive encephalopathy may require urgent antihypertensive therapy 1.
  • Eligibility for thrombolytic therapy: in patients eligible for thrombolytic therapy, blood pressure should be carefully managed to ensure it does not exceed systolic 185 mm Hg or diastolic 110 mm Hg 1. In the perioperative period for noncardiac surgery, caution is advised when continuing antihypertensive therapy in patients with low or low-normal blood pressures, older adults, and those at high risk for perioperative hypotension 1.
• It is recommended to restart preoperative antihypertensive medications as soon as clinically reasonable postoperatively to avoid complications from postoperative hypertension 1. The most recent and highest quality study, from 2024, provides guidance on perioperative cardiovascular management for noncardiac surgery, emphasizing the importance of careful blood pressure management to limit the risk of cardiovascular, cerebrovascular, renal events, and mortality 1.

From the FDA Drug Label

If a patient is treated with clonidine and metoprolol concurrently, and clonidine treatment is to be discontinued, stop metoprolol tartrate several days before clonidine is withdrawn Rebound hypertension that can follow withdrawal of clonidine may be increased in patients receiving concurrent beta-blocker treatment. In general, administration of a beta-blocker should be withheld before dipyridamole testing, with careful monitoring of heart rate following the dipyridamole injection.

The anti-hypertensive medication metoprolol should be held in the following situations:

• Several days before clonidine is withdrawn in patients receiving concurrent clonidine and metoprolol treatment 2
• Before dipyridamole testing, with careful monitoring of heart rate following the dipyridamole injection 2

From the Research

When to Hold Anti-Hypertensive Medication

• The decision to hold anti-hypertensive medication should be based on individual patient factors, such as the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 3.
• Temporary discontinuation of antihypertensive medication may be necessary for diagnostic evaluation of hypertension, and can be done safely in a well-controlled setting with appropriate protocols for monitoring safety 4.
• Discontinuation of medication was well tolerated in a study of 604 patients, with 62% reporting no complaints and 14% experiencing complaints that required prescription of antihypertensive escape medication 4.

Blood Pressure Targets

• The target blood pressure level for most patients is less than 130/80 mmHg, although this may vary depending on individual patient factors such as age and comorbidities 3.
• Reducing systolic blood pressure by 10 mmHg can decrease the risk of cardiovascular events by approximately 20-30% 3.

Special Considerations

• In patients with diabetes, the target blood pressure level is less than 130/80 mmHg, and combination therapy with an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) and a thiazide diuretic or calcium channel blocker may be necessary 5, 3.
• In patients with chronic kidney disease and proteinuria, combination therapy with an ACEI or ARB and a thiazide diuretic or calcium channel blocker is recommended 5.
• In patients with heart failure with reduced ejection fraction, treatment should be initiated with a beta blocker and an ACEI or ARB, followed by add-on therapy with a mineralocorticoid receptor antagonist and a diuretic based on volume status 5.