Perioperative Management of Telmisartan in HFpEF Patients Undergoing Laparoscopic Surgery
Continue telmisartan through the perioperative period for your HFpEF patient undergoing laparoscopic surgery tomorrow, as discontinuation risks worsening heart failure without proven benefit for this medication class. 1
Guideline-Based Recommendation for ARBs in Perioperative Setting
The 2024 ACC/AHA perioperative guidelines provide clear direction for patients with compensated heart failure undergoing noncardiac surgery:
It is reasonable to continue guideline-directed medical therapy (GDMT) in the perioperative period, unless contraindicated, to reduce the risk of worsening heart failure (Class 2a recommendation, Level C-LD evidence). 1
The only medication class specifically recommended for discontinuation is SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin should be stopped ≥3 days before surgery; ertugliflozin ≥4 days before). 1, 2
Telmisartan, as an angiotensin II receptor blocker (ARB), is not listed among medications requiring perioperative discontinuation. 1
Risk Context for HFpEF Patients
Your patient faces elevated perioperative risk that makes continuation of heart failure medications particularly important:
Patients with heart failure have 67% higher adjusted odds of 90-day mortality compared to those without heart failure undergoing noncardiac surgery. 1
HFpEF patients specifically had a 30-day mortality rate of 4.88% in large cohort studies, with crude odds ratio of 4.14 compared to patients without heart failure. 1
The 3-fold greater risk for perioperative death in heart failure patients compared to those with coronary artery disease alone underscores the importance of maintaining optimal medical management. 1
Pathophysiologic Rationale for Continuation
HFpEF patients are exquisitely sensitive to hemodynamic perturbations during surgery:
Profound left ventricular systolic and diastolic stiffening, elevated LV filling pressures, and reduced arterial compliance characterize HFpEF, making these patients highly vulnerable to acute declines in preload or afterload. 3
Discontinuing ARBs risks destabilizing compensated heart failure status during the critical perioperative period when hemodynamic stress is maximal. 1, 3
Hypertension is the most common comorbidity in HFpEF patients and is implicated in both pathogenesis and prognosis, making blood pressure control through ARB continuation essential. 4
Specific Management for ACE Inhibitors/ARBs in Heart Failure
The European Society of Cardiology guidelines, referenced in the evidence, recommend:
In patients with heart failure, ACE inhibitors or ARBs should be continued up until surgery and reinstated postoperatively as soon as clinical conditions permit. 5
This approach maintains hemodynamic stability and prevents decompensation of chronic heart failure during the perioperative period. 5
Common Pitfall to Avoid
Do not confuse the perioperative management of ARBs with SGLT2 inhibitors. While SGLT2 inhibitors require discontinuation 3-4 days before surgery due to metabolic acidosis risk 1, 2, ARBs like telmisartan have no such requirement and should be continued to maintain heart failure compensation. 1, 5
Practical Implementation
For your patient's laparoscopic surgery tomorrow:
Administer telmisartan on the morning of surgery with a sip of water. 1
Ensure appropriate hemodynamic monitoring during the procedure given the elevated perioperative risk in HFpEF patients. 1, 3
Resume normal medication schedule immediately postoperatively once oral intake is tolerated. 5
Monitor for signs of heart failure decompensation in the postoperative period, as HFpEF patients remain at elevated risk for complications. 1