In an 81‑year‑old man with prior stroke/TIA and coronary artery disease taking metoprolol succinate 75 mg daily, losartan 75 mg twice daily, and amlodipine 10 mg daily with stable blood pressure, which medications should be continued or held on the day of surgery and what pre‑operative blood pressure limits are acceptable?

Perioperative Antihypertensive Management

Continue metoprolol succinate and losartan on the day of surgery; hold amlodipine on the morning of surgery. 1

Medication-Specific Hold Parameters

Beta-Blocker (Metoprolol Succinate 75 mg daily)

• Continue through the morning of surgery with a small sip of water 1
• Abrupt withdrawal of beta-blockers causes dangerous heart rate and blood pressure rebound, particularly in patients with coronary artery disease 1
• In your patient with documented CAD, stopping metoprolol risks perioperative myocardial ischemia and infarction 1
• Beta-blockers are particularly protective against perioperative ischemic episodes when continued 1

ARB (Losartan 75 mg BID)

• Continue through the morning of surgery 1
• The 2016 Association of Anaesthetists/British Hypertension Society guidelines recommend continuing ACE inhibitors and ARBs in patients with established cardiovascular disease undergoing surgery 1
• Your patient's history of stroke and CAD places him in the high cardiovascular risk category where continuation outweighs withdrawal risks 1
• ARBs do not cause the same rebound hypertension as beta-blocker withdrawal 1

Calcium Channel Blocker (Amlodipine 10 mg daily)

• Hold on the morning of surgery 1
• Amlodipine has a long half-life (30-50 hours) and will maintain some effect even when held 1
• Holding reduces the risk of excessive intraoperative hypotension when combined with anesthetic agents 1
• Unlike beta-blockers, calcium channel blockers do not cause dangerous withdrawal phenomena 1

Acceptable Blood Pressure Parameters

Preoperative Blood Pressure Limits

• Proceed with surgery if systolic BP < 180 mmHg and diastolic BP < 110 mmHg 1
• Stage 3 hypertension (≥180/110 mmHg) requires case-by-case assessment: weigh the urgency of surgery against the time needed to optimize blood pressure control 1
• For your 81-year-old patient with prior stroke, maintaining systolic BP < 140 mmHg is the long-term target, but acute aggressive lowering immediately before surgery is not required 1

Intraoperative Blood Pressure Management

• Maintain mean arterial pressure ≥ 65 mmHg to ensure adequate cerebral and coronary perfusion 2
• In patients with prior stroke, avoid systolic BP drops > 20% below baseline due to impaired cerebral autoregulation 3
• Your patient's history of stroke means his cerebral vessels may have impaired autoregulation, making him more vulnerable to hypotension-induced cerebral ischemia 3

Postoperative Resumption

• Resume all three antihypertensive medications within 24 hours after surgery if the patient is hemodynamically stable and able to take oral medications 1
• If unable to take oral medications, consider transdermal clonidine or parenteral beta-blockers as alternatives 1

Critical Pitfalls to Avoid

• Never abruptly stop beta-blockers perioperatively in patients with CAD—this dramatically increases the risk of myocardial infarction and death 1
• Do not delay necessary surgery solely to achieve perfect blood pressure control in patients with Stage 1 or 2 hypertension (< 180/110 mmHg) 1
• Avoid aggressive intraoperative blood pressure lowering in elderly stroke patients, as cerebral perfusion depends on adequate systemic pressure when autoregulation is impaired 3
• Do not use phenylephrine as the sole vasopressor if intraoperative hypotension develops in a patient on beta-blockers, as it can cause reflex bradycardia 2