Should antihypertensive medications be held before coronary artery bypass grafting (CABG) surgery?

Management of Antihypertensive Medications Prior to CABG Surgery

Antihypertensive medications should be continued up to the morning of surgery and restarted promptly in the post-operative period. 1

Preoperative Management

Continue All Antihypertensive Medications

• All antihypertensive medications should be administered up to and including the morning of surgery in hemodynamically stable patients. 1, 2

• There is no clear evidence favoring discontinuation of any specific class of antihypertensive therapy before CABG. 1

• Beta-blockers are particularly important to continue, as they are recommended in the perioperative period for all high-risk patients with hypertension and concomitant ischemic heart disease. 1

Exception for Severe Hypertension

• In patients with grade 3 hypertension (systolic BP ≥180 mmHg and/or diastolic BP ≥110 mmHg), weigh the potential benefits of delaying surgery to optimize pharmacological therapy against the risks of delaying the surgical procedure. 1

• For grade 1 or 2 hypertension, there is no evidence that delaying surgery to optimize therapy is beneficial. 1

Postoperative Management

Immediate Reinitiation

• Restart antihypertensive therapy promptly in the post-operative period as soon as the patient is hemodynamically stable. 1

• Beta-blockers should be reinstituted as soon as possible after CABG in all patients without contraindications to reduce the incidence of atrial fibrillation. 3

• ACE inhibitors and ARBs should be reinstituted postoperatively once the patient is stable. 3

Cautious Approach to Dosing

• Treatment of hypertension should be started with caution using the lowest possible dosage and monitored individually. 2

• Aggressive therapy is strongly discouraged to avoid hemodynamic collapse. 2

• Maintain mean arterial pressure greater than 60 mmHg, particularly in patients with preexisting renal dysfunction. 3

Common Pitfalls to Avoid

Do Not Routinely Hold Antihypertensives

• The most common error is unnecessarily discontinuing antihypertensive medications before CABG, which contradicts guideline recommendations. 1

• Holding medications may lead to rebound hypertension and increased perioperative cardiovascular complications. 1

Avoid Intravenous Beta-Blockers

• Routine use of intravenous beta-blockers is not recommended to avoid uncontrolled hypotension. 1

• Oral beta-blockers should be used instead when possible. 1

Monitor for Hemodynamic Instability

• Rapid decreases in severely elevated blood pressure can cause cerebral infarction, optic nerve infarction, angina, and ischemic ECG changes. 4

• Blood pressure lowering should be achieved over as long a period as is compatible with the patient's status. 4

Special Considerations

Specific Medication Classes

• Statins: Never discontinue before or after CABG (Class III: HARM recommendation). 5

• Aspirin: Continue until the day of CABG and restart within 6 hours postoperatively if hemostasis is adequate. 1

• P2Y12 inhibitors: Discontinue clopidogrel ≥5 days before, prasugrel ≥7 days before, and ticagrelor ≥3 days before elective CABG. 1

Hemodynamic Monitoring

• Continuous ECG monitoring must be performed for at least 48 hours after CABG to detect arrhythmias. 3

• Hypertension occurs in more than one-third of patients after CABG, typically characterized by increased systemic vascular resistance. 6