Perioperative Management of ARBs: 24-Hour Hold Recommendation
Yes, all ARBs should be discontinued 24 hours before the day of surgery for noncardiac procedures, as this approach reduces intraoperative hypotension, death, stroke, and myocardial injury without increasing preoperative hypertension or adverse outcomes. 1, 2
Evidence-Based Rationale
The ACC/AHA guidelines explicitly recommend discontinuing ARBs 24 hours before major noncardiac surgery based on recent cohort evidence demonstrating superior outcomes compared to continuation. 1, 2 This recommendation applies uniformly to all ARB medications, as the class effect of renin-angiotensin system blockade creates predictable intraoperative hypotension risk under anesthesia. 2
Key Supporting Evidence
Discontinuation does not cause rebound hypertension: A prospective randomized trial of 526 patients demonstrated that stopping ACE inhibitors/ARBs on the day of surgery did not increase preoperative hypertension rates, with the upper confidence interval showing less than 5.8 percentage point increase in Stage 2 hypertension. 3
Continuation increases hypotension without benefit: A systematic review of 6,022 patients showed that continuing ARBs was associated with significantly more intraoperative hypotension (OR 0.63 for withholding, 95% CI 0.47-0.85) without any reduction in mortality or major cardiac events. 4
Cardiac surgery data shows no benefit to continuation: A randomized trial in cardiac surgery patients found no difference in vasopressor requirements, acute kidney injury, stroke, or mortality between continuation and discontinuation groups, with 96% protocol adherence. 5
Critical Management Algorithm
Preoperative Phase (24 Hours Before Surgery)
Hold all ARBs (losartan, valsartan, irbesartan, candesartan, telmisartan, olmesartan, azilsartan, eprosartan) regardless of specific agent or half-life. 1, 2
Continue other antihypertensives: Beta-blockers must be continued to avoid rebound hypertension and withdrawal syndrome. 6, 7 Calcium channel blockers should be continued as they do not cause significant intraoperative hypotension and reduce perioperative ischemia. 2, 7 Alpha-2 agonists (clonidine) must be continued to prevent rebound hypertension. 1
Managing Elevated Blood Pressure Without ARBs
Defer surgery if BP ≥180/110 mmHg: For elective major procedures, postpone surgery until better control is achieved using non-ARB medications. 1
Target BP <130/80 mmHg before major elective procedures using calcium channel blockers, beta-blockers, or other agents—but not ARBs in the immediate 24-hour preoperative window. 1
Intraoperative Management
Use IV antihypertensives for acute hypertension: If blood pressure elevation occurs intraoperatively after ARB discontinuation, administer clevidipine, esmolol, or nicardipine rather than restarting ARBs. 1
Do not restart ARBs intraoperatively: The risk of severe hypotension under anesthesia outweighs short-term hypertension management. 1
Postoperative Restart Protocol
Resume ARBs once hemodynamically stable: Restart when the patient has adequate volume status and oral intake is tolerated. 6, 2, 7
Monitor blood pressure closely after restart: Watch for postoperative hypotension as volume status normalizes. 1, 2
Important Exception
Left ventricular systolic dysfunction: Patients with significant LV dysfunction may benefit from continuing ARBs perioperatively under close hemodynamic monitoring, as this represents guideline-directed medical therapy for heart failure. 1, 2 However, this requires individualized assessment of bleeding risk versus cardiac decompensation risk and is not routine practice.
Common Pitfalls to Avoid
Never continue ARBs on surgery day even with elevated BP: The morbidity from severe intraoperative hypotension (which can be refractory to vasopressors due to angiotensin system blockade) exceeds the risk of short-term hypertension. 1
Never abruptly stop beta-blockers or clonidine: These medications cause dangerous rebound hypertension when discontinued, unlike ARBs which can be safely held. 1, 7
Do not confuse ARB management with ACE inhibitor management: While the evidence base includes both drug classes together, the 24-hour hold recommendation applies equally to both. 1, 2, 3