Perioperative Blood Pressure Medication Management
In most patients with hypertension undergoing noncardiac surgery, continue antihypertensive medications throughout the perioperative period, with the specific exception of ACE inhibitors and ARBs, which should be discontinued 24 hours before surgery. 1, 2
Preoperative Management by Drug Class
Continue Through Surgery
- Beta blockers: Must be continued in patients already taking them chronically to avoid rebound hypertension and associated risks of myocardial ischemia, acute heart failure, and dysrhythmias 1, 3, 2
- Calcium channel blockers: Should be continued through the day of surgery as they maintain blood pressure control without causing significant intraoperative hypotension 3, 4, 2
- Clonidine (alpha-2 agonists): Must be continued to within 4 hours of surgery to prevent dangerous rebound hypertension; abrupt discontinuation is potentially harmful 1, 2, 5
Discontinue Before Surgery
- ACE inhibitors and ARBs: Discontinue 24 hours before surgery, as recent evidence demonstrates lower rates of death, stroke, myocardial injury, and intraoperative hypotension compared to continuing these medications 1, 2
- Diuretics: Discontinue on the day of surgery and resume postoperatively 4, 6
Surgery Deferral Considerations
- Defer elective surgery if systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥110 mmHg, particularly in patients undergoing elevated-risk surgery with cardiovascular risk factors 1, 2
Intraoperative Blood Pressure Targets
Maintain mean arterial pressure (MAP) ≥60-65 mmHg or systolic blood pressure (SBP) ≥90 mmHg to reduce risk of myocardial injury, acute kidney injury, and mortality. 1, 3
Management of Intraoperative Hypertension
- Use intravenous antihypertensive agents when blood pressure exceeds 160/90 mmHg or SBP elevation >20% of preoperative value persisting >15 minutes 1
- Preferred IV agents include clevidipine, esmolol, nicardipine, and nitroglycerin 1, 2, 7
Management of Intraoperative Hypotension
- Treat hypotension (MAP <60-65 mmHg or SBP <90 mmHg) promptly to limit cardiovascular, cerebrovascular, and renal complications 1, 3
- Use fluid administration and vasoconstrictors (ephedrine, phenylephrine, or terlipressin) as needed 8
Postoperative Management
Restart antihypertensive medications as soon as clinically reasonable when the patient can tolerate oral intake to avoid complications from postoperative hypertension. 1, 3
Restart Protocol
- Resume medications once hemodynamically stable with adequate volume status 2
- Delaying resumption of antihypertensive medications is associated with increased 30-day mortality risk 3
- Monitor blood pressure closely after restarting, particularly when resuming ACE inhibitors/ARBs, to prevent postoperative hypotension 2
Special Considerations for Postoperative Period
- Exercise caution when restarting therapy in patients with low or low-normal perioperative blood pressures 1
- Older adults (≥65 years) may require higher blood pressure targets than younger patients 1
- If unable to take oral medications, use intravenous agents to control blood pressure 1
Critical Pitfalls to Avoid
- Never abruptly discontinue beta blockers or clonidine preoperatively, as this creates dangerous rebound hypertension 1, 2, 5
- Never start beta blockers on the day of surgery in beta blocker-naïve patients 1
- Do not continue ACE inhibitors/ARBs on the day of surgery even with elevated blood pressure, as the risk of severe intraoperative hypotension creates greater morbidity than short-term hypertension 2, 8
- Avoid tight blood pressure control in the immediate perioperative period in older adults or those with chronic hypertension, as higher targets may be more appropriate 1