Of note, this chapter does not include the perioperative management of anticoagulants, antiplatelets, glucocorticoids, and anticonvulsants, which are treated in separate chapters.
- Understand pathophysiology of patient’s various comorbidities and deduce if discontinuation of a particular drug would lead to disease progression
- Consider the possibility of withdrawal with an abrupt cessation of a particular drug
- Consider possible drug–drug interactions perioperatively
- Understand anticipated type of surgery, anesthesia, as well as the postoperative course
Table 9-1 Perioperative Management of Cardiovascular Agents |Favorite Table|Download (.pdf)
Table 9-1 Perioperative Management of Cardiovascular Agents
|Medication||Two days prior to surgery||One day prior to surgery||Morning of surgery||Perioperative considerations|
|Beta-blockers||Yes (do not stop)||Yes (do not stop)||Yes (do not stop)|
- Abrupt cessation may lead to hypertension, tachycardia, and myocardial ischemia
- If needed (and enough time), adjust dose for HR 60–70 without hypotension
- Shown to decrease perioperative risk of myocardial ischemia in patients with cardiac disease. Perioperative initiation not recommended (because of possible increased risk of CVA and mortality)
- Can bridge patient to IV forms
|Calcium channel blockers||Yes||Yes||Yes|
- Stop if patient hypotensive
- Abrupt cessation will not result in withdrawal effects
- Can bridge patient to IV forms
|Angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB)||Yes||Yes|
- Yes, if used to treat hypertension
- No, if used for other indications
- Continuation may lead to hypotension perioperatively
- Abrupt cessation may lead to rebound postoperative hypertension
- Intraoperative use of IV angiotensin to treat refractory hypotension has been reported
- No clear evidence of adverse effects of continuation; it might be less confusing for patients to take all HTN medications; however, this is controversial
- Known to cause orthostatic hypotension and dizziness
- Abrupt cessation may lead to severe rebound hypertension
- If patient is anticipated to restart PO clonidine within 12 h of preoperative dose, then clonidine should be continued up to and including day of surgery
- If patient will be unable to restart PO dose within 12 h of preoperative dose, then he or she should be bridged to patch form of clonidine 3 days prior to surgery
- PO dose should be tapered while patch form is initiated
- Continuation may lead to hypovolemia and electrolyte disturbances
- In combination with perioperative risk of muscle injury, may contribute to development of myopathy
- Perioperative use as cardioprotective agent still under investigation
- Administer postoperatively by NGT if unable to swallow
|Non-statin cholesterol lowering agents||Yes||No||No|
- Cholestyramine/colestipol binds bile acids in GI tract and hinders absorption of various medications
- Niacin/folic acid may lead to myopathy and rhabdomyolysis
- Transdermal forms may have decreased efficacy if skin perfusion is compromised
- Perioperative physiologic changes such as change in pH, hypoxia, electrolyte disturbances and use of other drugs ...
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