Perioperative Management of Amlodipine and Losartan for Cholecystectomy
You should discontinue losartan 24 hours before surgery but continue amlodipine on the morning of surgery with a small sip of water. 1, 2, 3
Losartan (ARB) - DISCONTINUE 24 Hours Before Surgery
The 2024 ACC/AHA perioperative guidelines explicitly recommend discontinuing ARBs 24 hours before noncardiac surgery based on recent cohort evidence demonstrating lower rates of death, stroke, myocardial injury, and intraoperative hypotension compared to continuing these medications. 1, 2
Why ARBs Must Be Stopped:
ARBs significantly increase the risk of severe intraoperative hypotension, particularly during anesthesia induction, which creates greater morbidity risk than short-term preoperative hypertension. 2, 4
A prospective randomized study demonstrated that patients who continued ARBs had significantly more hypotensive episodes (2±1 vs 1±1), longer duration of hypotension (8±7 min vs 3±4 min), and increased need for vasopressor support compared to those who discontinued ARBs the day before surgery. 4
Recent large cohort studies confirm that stopping ARBs 24 hours before surgery reduces the composite outcome of cardiovascular complications and intraoperative hypotension. 2, 3
Amlodipine (Calcium Channel Blocker) - CONTINUE on Day of Surgery
The 2024 ACC/AHA guidelines recommend continuing calcium channel blockers throughout the perioperative period, as they do not cause significant intraoperative hypotension that would warrant discontinuation. 1, 3
Why CCBs Should Be Continued:
Calcium channel blockers can generally be continued during noncardiac surgery and have been shown to reduce ischemia and supraventricular tachycardia in the perioperative period. 3, 5
The guidelines state it is reasonable to continue antihypertensive medications until the day of surgery, with the specific exception of ACE inhibitors and ARBs. 6
Amlodipine should be taken with a small sip of water on the morning of surgery to maintain blood pressure control and avoid rebound hypertension. 6
Critical Implementation Details:
Preoperative Blood Pressure Assessment:
If blood pressure is ≥180/110 mmHg despite holding the losartan, consider deferring elective surgery until better control is achieved. 1, 6
Target blood pressure <130/80 mmHg is reasonable before major elective procedures, though this should be achieved with medications other than ARBs in the immediate preoperative period. 1, 6, 2
Intraoperative Management:
If hypertension develops intraoperatively after losartan has been held, use IV antihypertensive agents such as clevidipine, esmolol, or nicardipine until oral medications can be resumed postoperatively. 1, 2
Maintain intraoperative MAP ≥60-65 mmHg or SBP ≥90 mmHg to reduce the risk of myocardial injury. 1
Postoperative Restart Protocol:
Restart losartan as soon as the patient is hemodynamically stable and volume status is adequate, typically when oral intake is tolerated. 1, 2, 3
Continue amlodipine postoperatively as soon as oral medications can be resumed to avoid complications from postoperative hypertension. 1
Monitor blood pressure closely after restarting losartan to prevent postoperative hypotension. 2, 3
Common Pitfalls to Avoid:
Do NOT continue losartan on the day of surgery even if blood pressure is elevated, as the risk of severe intraoperative hypotension creates greater morbidity than short-term hypertension. 2
Do NOT stop amlodipine abruptly, as calcium channel blockers do not carry the same hypotension risk as ARBs and should be continued for blood pressure control. 3, 5
Assess other contributing factors to perioperative hypertension such as volume status, pain control, oxygenation, and bladder distention before escalating pharmacological therapy. 1, 6
Be aware that one case report documented severe postoperative hypotension requiring vasopressor support in a patient on amlodipine for cholecystectomy, though this represents an isolated case rather than systematic evidence. 7