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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e183 diesterase-5 inhibitors are a safe and effective therapy for erectile dysfunction and can be administered with antihy pertensive medications. Caution should be exercised when sildenafil, tadalafil, vardenafil, and avanafil are coadminis tered with CYP3A4 inhibitors (such as diltiazem, verapamil; Section 5.2.6, “Medication Interactions”) or ingested with grapefruit juice or alcohol, which may increase the risk of hypotension. These drugs should not be taken with nitrates due to the risk of severe hypotension. 6.4 Patients Scheduled for Surgical Procedures Recommendations for Patients Scheduled for Surgical Procedures Referenced studies that support the recommendations are summarized in the Evidence Table. COR LOE Recommendations 1 B-NR 1 In patients with hypertension scheduled for major surgery who have been on BBs chronically, BBs should be continued throughout the perioperative period to assist with BP control.1–5 2a C-EO 2 In patients with hypertension scheduled for elective major surgery, it is reasonable to continue most medications for hypertension throughout the perioperative period. 2b B-R 3 In patients with hypertension scheduled for major surgery, discontinuation of ACEi or ARB preopera tively may be considered to prevent hypotension during surgery.6–10 2b C-LD 4 In patients scheduled for elective major surgery with SBP ≥180 mm Hg or DBP ≥110 mm Hg, deferring surgery may be considered especially in high-risk patients to minimize perioperative complications.11–13 3: Harm B-NR 5 In patients with hypertension scheduled for surgery, abrupt preoperative discontinuation of BB or clonidine may result in rebound hypertension and is potentially harmful.14 3: Harm B-R 6 For patients with hypertension scheduled for surgery, BB should not be started on the day of surgery in BB-naïve patients because of increased risk of postoperative mortality.4,15,16 Synopsis Hypertension in the perioperative period increases the risk of cardiovascular and cerebrovascular events and bleed ing.17,18 As many as 25% of patients who undergo major noncardiac surgery and 80% of patients who have car diac surgery experience perioperative hypertension.18–20 In general, the level of risk is related to the severity of the hypertension. Uncontrolled hypertension is associated with increased perioperative and postoperative complications. Certain medications (eg, BB, clonidine) may be associ ated with rebound hypertension if discontinued abruptly. In addition to RCT results, several general strategies and Table 27. Intravenous Antihypertensive Drugs for Treatment of Hypertensive Emergencies in Patients With Selected Comorbidities Comorbidity Preferred Drug(s)* Comments Acute aortic dissection Esmolol, labetalol Requires rapid lowering of SBP to ≤120 mm Hg. Beta blockade should precede vasodilator (eg, nicardipine or nitroprusside) admin istration, if needed for BP control or to prevent reflex tachycardia or inotropic effect; SBP ≤120 mm Hg should be achieved within 20 min. Acute pulmonary edema Clevidipine, nitroglycerin, nitroprusside Beta blockers contraindicated. Acute coronary syndromes Esmolol†, labetalol, nicardipine, nitro glycerin† Nitrates given in the presence of PDE-5 inhibitors may induce profound hypotension. Contraindications to beta blockers include moderate-tosevere LV failure with pulmonary edema, bradycardia (<60 beats/min), hypotension (SBP <100 mm Hg), poor peripheral perfusion, second- or third-degree heart block, and reactive airways disease. Acute kidney injury Clevidipine, fenoldopam, nicardipine N/A Eclampsia or preeclampsia Hydralazine, labetalol, nicardipine, nifedipine Requires rapid BP lowering. ACE inhibitors, ARB, renin inhibitors, and nitroprusside contraindicated. Perioperative hypertension (BP ≥160/90 mm Hg or SBP elevation ≥20% of the preopera tive value that persists for >15 min) Clevidipine, esmolol, nicardipine, nitroglycerin Intraoperative hypertension is most frequently seen during anesthesia induction and airway manipulation. Acute sympathetic discharge or catechol amine excess states (eg, pheochromocy toma, postcarotid endarterectomy status) Clevidipine, nicardipine, phentolamine Requires rapid lowering of BP. Acute ICH Clevidipine, nicardipine, esmolol, labetalol, hydralazine Section 5.3.9.1 Acute ischemic stroke Clevidipine, nicardipine, esmolol, labetalol, hydralazine Section 5.3.9.2 Modified with permission from Whelton et al.1 Copyright 2018 American College of Cardiology Foundation and American Heart Association, Inc. *Agents are listed in alphabetical order, not in order of preference. †Agent of choice for acute coronary syndromes. ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; ICH, intracerebral hemorrhage; LV, left ventricular; PDE-5, phosphodiesterase type-5; and SBP, systolic blood pressure. Recommendations for Patients Scheduled for Surgical Procedures (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026