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Opinions vary on which of their prescribed antihypertensive medications patients should take on the morning of major surgery. In this retrospective study, researchers examined rates of postoperative acute kidney injury (AKI) in 405 drug-treated hypertensive patients who underwent suprainguinal vascular (mostly aortic) surgery. The researchers defined AKI as an increase in serum creatinine ≥0.3 mg/dL or 50% above baseline level.
On the morning of surgery, 47% of patients took none of their antihypertensive drugs, 29% took one drug, and 24% took two or more drugs. Decisions to take or hold medications preoperatively were made by the patients' physicians. The incidence of postoperative AKI was 7%, 13%, and 14% among patients who took none, 1, or ≥2 medications, respectively, on the morning of surgery. On multivariable analysis, patients who took 1 drug had nonsignificantly higher risk for AKI (adjusted odds ratio, 1.6), and those who took ≥2 drugs had significantly higher risk (aOR, 2.7). No data were given on severity of AKI or effects of individual drug classes.
Duceppe E et al. Preoperative antihypertensive medication intake and acute kidney injury after major vascular surgery J Vasc Surg 2018 Jun; 67:1872. (https://doi.org/10.1016/j.jvs.2017.10.065)
Comment
This study suggests that withholding antihypertensive drugs on the morning of suprainguinal vascular surgery might be prudent; whether the findings apply to other types of surgery is unclear. Another recent observational study suggested fewer postoperative cardiovascular complications when angiotensin-converting–enzyme (ACE) inhibitors were withheld prior to noncardiac surgery (NEJM JW Gen Med Feb 1 2017 and Anesthesiology 2017; 126:16). U.S. guidelines recommend continuing β-blockers before noncardiac surgery but don't give decisive guidance for other drug classes (NEJM JW Gen Med Dec 1 2014 and J Am Coll Cardiol 2014; 64:77). Absent such guidance, my personal practice has been to hold thiazide diuretics (to avoid giving a drug with fluid/electrolyte effects) but to give ACE inhibitors, angiotensin-receptor blockers, and calcium-channel blockers, unless a patient's blood pressure consistently has been on the low side.