Perioperative Management of Telmisartan/Amlodipine in Patients with CVD and Bleeding History
Yes, you should continue both telmisartan and amlodipine perioperatively for your total abdominal hysterectomy, even with a history of cardiovascular disease and prior bleeding. 1
Primary Recommendation
The 2014 ACC/AHA guidelines explicitly state that continuation of ACE inhibitors or ARBs (including telmisartan) is reasonable perioperatively (Class IIa, Level B recommendation). 1 Calcium channel blockers like amlodipine are not mentioned as requiring discontinuation and should be continued to maintain cardiovascular stability. 1
Key Evidence Supporting Continuation
Telmisartan (ARB) should be continued: The ACC/AHA guidelines recommend continuation of angiotensin receptor blockers perioperatively as a Class IIa recommendation with Level B evidence. 1
If held, restart immediately postoperatively: If your surgical team decides to hold telmisartan on the day of surgery due to hemodynamic concerns, the ACC/AHA guidelines state it is reasonable to restart as soon as clinically feasible postoperatively (Class IIa, Level C). 1
Amlodipine continuation is standard: Calcium channel blockers are not listed among medications requiring perioperative discontinuation and should be maintained for cardiovascular protection. 1
Important Distinction: Your Medications Are NOT Antiplatelet Agents
This is critical: Your question mentions "CVD bleed history," but telmisartan and amlodipine do NOT increase bleeding risk—they are not antiplatelet or anticoagulant medications. 2, 3, 4
Telmisartan is an angiotensin II receptor blocker used for blood pressure control and cardiovascular protection, not an antiplatelet agent. 2
Amlodipine is a calcium channel blocker that lowers blood pressure through vasodilation, with no effect on platelet function or coagulation. 3, 4, 5, 6
Prior bleeding history is NOT a contraindication to continuing these medications perioperatively, as they do not affect hemostasis. 1
Practical Perioperative Algorithm
| Timing | Action | Rationale |
|---|---|---|
| Preoperative (day before surgery) | Continue both telmisartan and amlodipine at usual doses | Maintains cardiovascular stability and blood pressure control [1] |
| Morning of surgery | Option A: Continue both medications with small sip of water Option B: Hold telmisartan only if anesthesiologist concerned about intraoperative hypotension; continue amlodipine |
ACC/AHA supports continuation (IIa/B) but allows holding if hemodynamic concerns [1] |
| Intraoperative | Anesthesia team monitors blood pressure and adjusts vasopressors as needed | Standard anesthetic management [1] |
| Postoperative day 1 | Resume both medications as soon as patient tolerating oral intake and hemodynamically stable | ACC/AHA recommends restarting as soon as clinically feasible [1] |
Common Pitfalls to Avoid
Do not confuse ARBs/calcium channel blockers with antiplatelet agents: The evidence you may have seen about discontinuing medications perioperatively applies to aspirin, clopidogrel, and NSAIDs—NOT to telmisartan or amlodipine. 1, 7, 8, 9
Do not stop these medications days in advance: Unlike antiplatelet agents that require 5-7 days for washout, ARBs and calcium channel blockers can be taken the morning of surgery or held only on the day of surgery if needed. 1
Communicate clearly with your surgical and anesthesia teams: Explicitly state you are on telmisartan/amlodipine (NOT antiplatelet agents) so they understand these medications do not increase surgical bleeding risk. 1
Special Considerations for Your CVD History
Your cardiovascular disease history is actually a reason TO continue these medications, not to stop them. 1
Patients with established CVD benefit from perioperative continuation of renin-angiotensin system blockers and calcium channel blockers to prevent perioperative cardiac events. 1
Abrupt discontinuation can cause rebound hypertension and increase cardiovascular risk in the perioperative period. 1
Your prior bleeding history is unrelated to telmisartan/amlodipine use, as these medications have no anticoagulant or antiplatelet effects. 2, 3, 4, 5, 6
Final Recommendation
Continue both telmisartan and amlodipine through your surgery. Discuss with your anesthesiologist whether to take them the morning of surgery with a sip of water (preferred) or hold only the telmisartan on the day of surgery if there are specific hemodynamic concerns. Resume both medications on postoperative day 1 when you can tolerate oral intake. Your history of bleeding is not a contraindication to these medications. 1