Authors: Tang J et al.
Anesthesiology 144(4):967–977, April 2026
Summary:
This comprehensive review addresses the complex and often controversial management of chronic antihypertensive medications in the perioperative period. It synthesizes recent randomized trials, guidelines, and observational data to provide a practical, patient-centered framework for decision-making.
A central theme is that there is no one-size-fits-all approach. For renin–angiotensin system inhibitors (ACE inhibitors and ARBs), recent randomized trials show no significant difference in major postoperative outcomes whether these medications are continued or held preoperatively. However, continuation increases intraoperative hypotension, while withholding increases postoperative hypertension—highlighting a trade-off rather than a clear benefit of either strategy.
β-blockers stand out as one of the few classes with consistent recommendations: they should be continued in patients already taking them, particularly those with cardiovascular disease. However, initiating β-blockers shortly before surgery is harmful and associated with increased stroke, hypotension, and mortality.
For calcium channel blockers and diuretics, the evidence is limited. Most guidelines suggest continuing these medications in stable patients, with individualized adjustments based on hemodynamics, comorbidities, and surgical risk. Diuretics, especially loop diuretics, require caution due to potential electrolyte disturbances and hypovolemia.
The article also emphasizes the importance of postoperative management. Delayed resumption of chronic antihypertensives—particularly ACE inhibitors and ARBs—may increase mortality risk, while aggressive treatment of transient postoperative hypertension in otherwise stable patients may actually worsen outcomes.
Ultimately, the authors advocate for individualized, physiology-based decision-making that considers patient comorbidities, surgical context, and medication-specific risks rather than rigid protocols.
Key Points:
- No clear outcome difference between continuing vs. holding ACE inhibitors/ARBs
- Continuation → more intraoperative hypotension; withholding → more postoperative hypertension
- β-blockers should be continued, but not newly started immediately before surgery
- Limited evidence for calcium channel blockers and diuretics—manage case by case
- Early postoperative resumption of chronic medications is important
- Avoid aggressive treatment of transient postoperative hypertension in stable patients
What You Should Know:
This isn’t about right vs. wrong—it’s about trade-offs. Almost every decision shifts risk from one phase (intraop hypotension) to another (postop hypertension). The key is knowing your patient and picking the lesser risk—not blindly following a rule.
We would like to thank Anesthesiology for allowing us to summarize and share this article.