ARB Discontinuation Before Facelift Surgery
ARBs should be discontinued at least 24 hours before facelift surgery to prevent severe intraoperative hypotension that occurs during anesthetic induction, particularly when combined with general anesthesia agents.
Primary Mechanism of Risk
The core issue is that ARBs block the renin-angiotensin-aldosterone system, which normally compensates for the vasodilatory effects of anesthetic agents. 1, 2 When this compensatory mechanism is blocked:
- Severe hypotension occurs specifically at induction of general anesthesia, when anesthetic agents cause vasodilation but the body cannot mount an appropriate vasoconstrictor response 3
- The hypotension is often refractory to standard vasopressors (ephedrine, phenylephrine) and may require alternative agents like vasopressin or terlipressin 4, 3
- Risk is amplified when ARBs are combined with beta-blockers, creating a "double block" of compensatory mechanisms 1
Evidence-Based Timing
The 24-hour discontinuation window is the minimum recommended timeframe, though evidence suggests this may not always be sufficient:
- The European Society of Cardiology specifically recommends holding ARBs 24 hours before non-cardiac surgery in patients taking them for hypertension 1, 2
- Studies demonstrate that patients continuing ARBs until surgery experience significantly more hypotensive episodes (mean 2±1 vs 1±1 episodes), longer duration of hypotension (8±7 vs 3±4 minutes), and greater vasopressor requirements compared to those who discontinued 24 hours prior 3
- Critical caveat: A case report documented severe refractory hypotension even after 48 hours of ARB discontinuation, requiring 96 hours of withdrawal before safe anesthesia 4
Clinical Application for Facelift Surgery
For elective facelift procedures under general anesthesia:
- Discontinue ARBs at least 24 hours preoperatively as the standard approach 1, 2
- Consider longer discontinuation periods (48-96 hours) for patients on long-acting ARBs like azilsartan or those with additional risk factors 4
- Ensure adequate preoperative hydration, as volume depletion exacerbates ARB-related hypotension 2
- Have vasopressin immediately available in the operating room, as catecholamine-based vasopressors may be insufficient 4, 3
Important Exception
Do NOT discontinue ARBs in patients with left ventricular systolic dysfunction (heart failure with reduced ejection fraction), as the cardiac benefits outweigh hypotension risks in this population. 1, 2 These patients should continue ARBs perioperatively with close hemodynamic monitoring. However, this scenario is uncommon in elective cosmetic surgery patients.
Postoperative Management
- Restart ARBs once hemodynamically stable and volume status is adequate, typically within 24-48 hours postoperatively 1, 2
- Monitor blood pressure closely after restarting to prevent postoperative hypotension 2
Contrast with Other Antihypertensives
Unlike ARBs, calcium channel blockers and beta-blockers should generally be continued through surgery, as they do not cause the same degree of refractory hypotension and provide protective cardiovascular effects. 2, 5