Should a patient with cardiomegaly and hypertension, taking telmisartan (angiotensin II receptor antagonist), discontinue telmisartan prior to undergoing a laparoscopic cholecystectomy?

Perioperative Management of Telmisartan for Laparoscopic Cholecystectomy

Discontinuation of telmisartan on the morning of surgery may be considered for this patient undergoing laparoscopic cholecystectomy, as angiotensin receptor blockers increase the risk of intraoperative hypotension and associated cardiac and renal complications. 1

Guideline Recommendations

The most recent ACC/AHA guidelines (2017) provide a Class IIb recommendation that discontinuation of ARBs perioperatively may be considered in patients undergoing major surgery. 1 This reflects moderate-quality evidence showing that patients taking angiotensin II receptor antagonists are more likely to develop intraoperative hypotension than those not on these medications. 1

Key Evidence Supporting Discontinuation

• Patients on ARBs have increased risk of intraoperative hypotension, which has been associated with greater incidence of perioperative cardiac and renal complications in some studies. 1

• The European Society of Cardiology recommends that transient discontinuation of ARBs before non-cardiac surgery should be considered to reduce hemodynamic instability during anesthesia. 2

• Telmisartan should be held 24 hours before surgery to allow adequate washout while minimizing rebound hypertension risk, given its long half-life. 2

Clinical Decision Algorithm

Proceed with Discontinuation if:

• Blood pressure is well-controlled (consistently <180/110 mm Hg) 1
• Patient has no acute heart failure or recent decompensation 1
• Surgery is elective and can accommodate medication adjustment 1

Consider Continuing if:

• Patient has severe, difficult-to-control hypertension requiring multiple agents 1
• Recent history of hypertensive urgency or emergency 1

Important Caveats and Pitfalls

Do NOT abruptly discontinue if the patient is also on beta-blockers or clonidine - these must be continued to avoid potentially harmful rebound hypertension. 1 Only the ARB should be held.

Cardiomegaly Considerations

The presence of cardiomegaly suggests chronic hypertension or possible heart failure. 1 If cardiomegaly is due to heart failure rather than just hypertensive heart disease, ensure the patient is euvolemic before surgery, as this affects the safety of withholding the ARB. 1

Intraoperative Management

Anticipate the need for vasopressor support if telmisartan is discontinued, as patients previously on ARBs may have impaired vasopressor response during anesthesia induction. 2 Maintain mean arterial pressure ≥60-65 mm Hg to reduce risk of myocardial injury and acute kidney injury. 3

Postoperative Resumption

Resume telmisartan as soon as the patient is euvolemic and tolerating oral medications, typically within 24 hours postoperatively. 1, 3, 2 Delaying resumption beyond 30 days has been associated with increased mortality risk. 2 Ensure adequate volume status before restarting to minimize risk of postoperative renal dysfunction. 1

Contradictory Evidence Note

One small study (n=40) suggested telmisartan 40mg given 2 hours preoperatively may offer nephroprotection during laparoscopic cholecystectomy. 4 However, this contradicts the broader guideline consensus and larger body of evidence showing increased hypotension risk. The guidelines from ACC/AHA and ESC, based on larger populations and multiple studies, should take precedence. 1, 2