Can a patient with hypertension continue taking SARTAM H (losartan + hydrochlorothiazide) up to the day of humerus fracture surgery?

Perioperative Management of SARTAM H for Humerus Fracture Surgery

For a patient with hypertension taking SARTAM H (losartan + hydrochlorothiazide) scheduled for humerus fracture surgery, you may consider omitting the medication 24 hours before surgery to limit intraoperative hypotension, though continuation is also reasonable depending on blood pressure control and surgical risk. 1

Key Decision Points

Blood Pressure Assessment

• Proceed with surgery if blood pressure is <180/110 mm Hg while continuing antihypertensive therapy until the morning of surgery 1
• If blood pressure is ≥180/110 mm Hg (grade 3 hypertension), weigh the benefits of delaying surgery to optimize blood pressure control against the risks of delaying fracture repair 1
• For grade 1 or 2 hypertension, there is no evidence that delaying surgery to optimize therapy provides benefit 1

RAAS Inhibitor Management (Losartan Component)

The 2024 ACC/AHA guidelines provide nuanced recommendations for the losartan component of SARTAM H:

• Omitting losartan 24 hours before surgery may be beneficial in select patients with controlled blood pressure undergoing elevated-risk procedures to limit intraoperative hypotension 1
• The 2018 ACC/AHA guidelines note that discontinuation of ACE inhibitors or ARBs perioperatively may be considered, though this is a weaker recommendation (Class IIb) 1
• Recent evidence from the POISE-3 trial (nearly 7,500 patients) showed no difference in major vascular events whether ACE inhibitors/ARBs were continued or withheld, with 72% of patients taking these medications 1

Hydrochlorothiazide Component

• Continue the thiazide diuretic component through the perioperative period as general antihypertensive therapy should be maintained 1
• Monitor volume status carefully, as orthopedic surgery may involve fluid shifts 1

Practical Algorithm

Option 1 (Preferred for controlled BP + elevated surgical risk):

• Omit SARTAM H on the morning of surgery (24 hours before)
• Resume as soon as patient can tolerate oral medications postoperatively 1, 2
• Manage intraoperative blood pressure with IV agents as needed 1

Option 2 (Reasonable for well-controlled BP + lower surgical risk):

• Continue SARTAM H until morning of surgery 1
• Be prepared to treat intraoperative hypotension aggressively 1
• Resume immediately postoperatively 2

Critical Intraoperative Targets

• Maintain mean arterial pressure (MAP) ≥60-65 mm Hg or systolic blood pressure ≥90 mm Hg to reduce risk of myocardial injury, acute kidney injury, and mortality 1, 2
• Intraoperative hypotension (MAP <65 mm Hg for >15 minutes) is associated with significant postoperative complications 2
• Have IV antihypertensive agents available if needed 1

Postoperative Management

• Resume SARTAM H as soon as clinically reasonable postoperatively, ideally when the patient can tolerate oral medications 1, 2
• Delaying resumption of antihypertensive medications is associated with increased 30-day mortality risk 2
• Provide adequate pain control, as pain increases sympathetic tone and blood pressure 3

Critical Pitfalls to Avoid

• Never abruptly discontinue beta-blockers or clonidine if the patient were taking these medications, as this causes potentially harmful rebound hypertension 1, 3
• Do not allow excessive hypotension in the immediate postoperative period; treat aggressively to prevent end-organ damage 1, 2
• Avoid delaying fracture surgery unnecessarily for blood pressure optimization unless BP is ≥180/110 mm Hg 1

Evidence Considerations

The European Society of Cardiology guidelines clearly state that "antihypertensive therapy should be continued up to the morning of surgery and restarted promptly in the post-operative period" 1. However, the more recent 2024 ACC/AHA guidelines introduce nuance specifically for RAAS inhibitors, noting that omission 24 hours before surgery may limit intraoperative hypotension in select patients 1. This represents evolving evidence, though the clinical significance of intraoperative hypotension versus maintaining chronic therapy remains debated. The POISE-3 trial suggests both approaches are safe 1.