Practice Perfect 910
The Pod Periop Medical Management Series # 4: Cardiac-Related Medications

Last week, in our ongoing series about perioperative medicine for the podiatrist, we discussed the preoperative cardiac exam, emphasizing the role of risk stratification with functional capacity and the Revised Cardiac Risk Index, downplaying the importance of the electrocardiogram. Today, as promised, we’ll deliver a quick, high-yield reference covering the use of cardiac-related medications in the perioperative period. In short, the question today is, “What medications should be continued, and which ones should be held around the time of surgery?” Let’s get right to it.

Note: Recommendations are excerpted from the 2014 ACC/AHA guidelines on perioperative management in the noncardiac surgery1 unless cited separately.

Medication Class Examples Recommendation
Medications for Pulmonary Hypertension
Phosphodiesterase type 5 inhibitors sildenafil, tadalafil,
vardenafil, and avanafil
Continue periop.
Soluble guanylate
cyclase stimulators
Endothelin receptor antagonists macitentan, ambrisentan and bosentan Continue
Medications for Hypertension
Beta blockers atenolol, bisoprolol, carvedilol, nebivolol, metoprolol, propranolol Continue if already on.

Do not start if not previously taking.
Alpha blockers doxazosin, prazosin, terazosin, tamsulosin Continue
Alpha-2 agonists clonidine Continue
ACE inhibitors benazapril, captopril, enalapril, lisinopril, ramipril Hold 24 hours preop2
Angiotension Receptor Blockers (ARBs) valsartan, olmesartan, losartan, irbesartan Hold 24 hours preop.
Calcium channel blockers amlodipine, diltiazem, nifedipine, verapamil, nicardipine Continue
Thiazide diuretics chlorthalidone, hydrochlorothiazide, metolazone Continue
Loop diuretics furosemide, bumetanide, torsemide Hold on day of surgery unless concern for volume overload
Potassium-sparing diuretics amiloride, spironolactone, triamterene Continue
Medications for Cholesterol Disorders
HMG-CoA Reductase Inhibitors (Statins) atorvastatin, lovastatin Continue
Bile Acid Sequestrants cholestyramine, colesevelam, colestipol Hold on day of surgery.
Nicotinic Acid niacin Hold on day of surgery.
Fibrates fenofibrate Hold on day of surgery.
Antiplatelet Agents
Aspirin   Continue unless increased bleeding risk.
P2Y12 Inhibitors clopidogrel Discontinue 3 days preop.3
Vitamin K Antagonists warfarin Discontinue > 3 days preop or cancel surgery. Bridging no longer recommended.4
Factor Xa Inhibitors rivaroxaban, apixaban Discontinue 24 - 96 hours preop. Restart 6 hours postop.5
Direct thrombin inhibitors dabigatran Discontinue 24 - 96 hours preop. Restart 6 hours postop.

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One quick final note regarding ACE inhibitors. It was previously recommended by the ACC/AHA guidelines to continue these medications perioperatively, but subsequent research found an increased risk of hypotension. It’s now recommended that ACE inhibitors and ARBs be held on the day of surgery.

It’s now recommended that ACE inhibitors and ARBs be held on the day of surgery.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

  1. Fleisher LA, Fleischmann K, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC 2014 Dec 9;64(22):e77-137.
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  2. Roshanov PS, Rochwerg B, Patel A, et al. Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers Before Noncardiac Surgery: An Analysis of the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation Prospective Cohort. Anesthesiology. 2017 Jan;126(1):16-27.
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  3. Chaya BF, Rodriguez Colon R, Boczar D, et al. Perioperative Medication Management in Elective Plastic Surgery Procedures. Journal Craniofac Surg. 2023 May 1;34(3):1131-1136.
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  4. Smilowitz NR, Berger JS. Perioperative Cardiovascular Risk Assessment and Management for Noncardiac Surgery: A Review. JAMA. 2020 Jul 21;324(3):279-290.
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  5. Chen A, Stecker E, Warden BA. Direct Oral Anticoagulant Use: A Practical Guide to Common Clinical Challenges. J Am Heart Assoc. 2020 Jul 7;9(13):e017559.
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