Which antihypertensive medication is appropriate for a 55-year-old man with hypertension and a resting heart rate of 60 beats per minute who requires oral surgery?

Appropriate Antihypertensive for Perioperative Hypertension with Baseline Bradycardia

For a 55-year-old man with hypertension and a resting heart rate of 60 bpm requiring oral surgery, avoid beta-blockers and use a calcium channel blocker (amlodipine or nicardipine) or an ACE inhibitor/ARB as the appropriate antihypertensive medication. 1

Critical Contraindication

• Isolated hypertension with a low heart rate (<60 beats/min) should NOT be treated with a non-selective beta blocker, as this can precipitate dangerous bradycardia in the perioperative setting 1
• Beta-blockers like labetalol, while commonly used for perioperative hypertension, are specifically contraindicated when the heart rate is already at or below 60 bpm 1

Recommended Medication Classes

Calcium Channel Blockers (First Choice)

• Nicardipine is preferred for perioperative hypertension management, achieving therapeutic blood pressure control in approximately 12 minutes and demonstrating superior efficacy compared to labetalol in achieving short-term blood pressure targets 1, 2
• Amlodipine is an excellent oral option for long-term management, particularly appropriate for patients over 55 years old 3
• Calcium channel blockers effectively lower blood pressure without affecting heart rate, making them ideal when baseline bradycardia is present 1

ACE Inhibitors or ARBs (Alternative)

• These agents are first-line antihypertensive medications that do not cause bradycardia 3
• Resume any preoperative ACE inhibitors or ARBs as soon as clinically feasible, as delayed resumption has been associated with increased 30-day mortality 2, 4
• If the patient is not currently on antihypertensives, initiation of an ACE inhibitor or ARB is appropriate for long-term management 3

Perioperative Management Algorithm

Preoperative Assessment

• Confirm the patient's baseline blood pressure and current medications 1
• Ensure chronic antihypertensive medications (except ACE inhibitors/ARBs on the day of surgery, which may be held) are continued through the perioperative period 2
• Never initiate beta-blockers on the day of surgery in beta-blocker-naïve patients, as this is associated with increased perioperative cardiovascular complications (Class III Harm) 2

Blood Pressure Target

• Target blood pressure approximately 10% above the patient's baseline preoperative value 1, 2
• Avoid excessive blood pressure reduction, which can cause hypotension-related myocardial infarction and death 2

Postoperative Management

• Assess for reversible causes of hypertension including pain, anxiety, hypothermia, hypoxemia, and urinary retention before initiating pharmacologic therapy 1, 2
• Resume oral antihypertensive medications as soon as the patient can tolerate oral intake 1, 2
• If intravenous therapy is needed postoperatively, nicardipine provides rapid, titratable blood pressure control without affecting heart rate 1, 2

Common Pitfalls to Avoid

• Do not use labetalol or other beta-blockers when the heart rate is 60 bpm or below, as reflex bradycardia can occur, especially in the preload-independent state 1
• Do not use phenylephrine for hypotension in this patient, as it can cause reflex bradycardia, particularly problematic given the baseline heart rate of 60 bpm 1
• Avoid immediate-release nifedipine for acute blood pressure management, as it causes unpredictable and potentially dangerous blood pressure drops 5
• Do not delay resumption of chronic antihypertensives (particularly ACE inhibitors/ARBs) in the postoperative period, as this increases mortality risk 2, 4

Specific Medication Recommendations

For Oral Surgery Setting

• Amlodipine 5-10 mg daily is appropriate for chronic management, as it provides 24-hour blood pressure control without affecting heart rate 3
• Lisinopril or losartan are alternative first-line agents that can be safely used with baseline bradycardia 3
• Ensure adequate pain control during and after the procedure, as inadequate analgesia is a primary driver of postoperative blood pressure elevation 2

Monitoring Requirements

• Monitor blood pressure and heart rate closely throughout the perioperative period 1
• Ensure the patient has adequate follow-up within 1-2 weeks to reassess blood pressure control 4