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CLINICAL STATEMENTS AND GUIDELINES

September 16, 2025 Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 e184

principles based on experience and observation are rec­ ommended for this section. In the management of patients with perioperative hypertension, it is important to assess other potential contributing factors, such as volume status, pain control, oxygenation, and bladder distention, when the use of pharmacological therapy to control BP is under consideration. For additional recommendations on periop­ erative hypertension management for noncardiac surgery, including the use of BB, ACEi, and ARB, please refer to the “2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/ SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery.”21

Recommendation-Specific Supportive Text

1 If well tolerated, BBs should be continued in patients

who are currently receiving them for GDMT indica­ tions (eg, recent MI, hypertension, arrhythmias). Multiple observational studies support the benefits of continuing BBs in patients who are undergoing sur­ gery and who are taking these agents for GDMT.1,3,4 Clinical judgment is useful in titrating BB during the perioperative period, focusing on continuing the medication through the hospital stay and at discharge unless clear contraindications arise. 2.	 In the absence of conclusive RCTs, the expert opinion of this writing committee is that control of BP to levels recommended by this guideline (BP <130/80 mm Hg) or other target levels speci­ fied for a particular individual is reasonable before undertaking major elective procedures in either the inpatient or outpatient setting. If the patient is unable to take oral medications, it is reasonable to use IV medications as necessary to control BP. Special consideration of parenteral therapy usually occurs for patients taking clonidine or BB because of the risk associated with stopping these medica­ tions acutely. Withdrawal syndromes, accompanied by sympathetic discharge and acute hypertension, can occur on cessation of these agents.16 Caution is advised when continuing antihypertensive ther­ apy in patients with low perioperative BPs, older adults (age ≥65 years),22 and patients in whom the risk for perioperative hypotension is high. 3.	 Data on the potential risk and benefit of ACEi in

the perioperative setting have been mostly limited to observational analyses and are controversial. Evidence from a large cohort study demonstrates that patients who stopped their ACEi or ARB 24 hours before noncardiac surgery were less likely to suffer the primary composite outcome (all-cause death, stroke, or myocardial injury) and intraoperative hypotension than were those continuing these med­ ications until surgery.10 However, the results from POISE-3 (Perioperative Ischemic Evaluation-3), which randomized 7490 patients undergoing noncardiac surgery with at least 1 high-risk factor, did not find a significant difference between patients randomized to a strategy that involved perioperative discontinuation of ACEi/ARB therapy and those with maintenance of such therapy during the opera­ tive and immediate perioperative periods.9 Omitting RAASi before surgery has been shown to reduce intraoperative hypotension, whereas RCTs have failed to prove their continuation or implementation improves clinical outcomes.6,7,23

4 There is conflicting evidence for patients with DBP

>110 mm Hg regarding recommending delay of sur­ gery to provide for gradual reduction in DBP before proceeding with surgery.24 In a systematic review and meta-analysis, preoperative hypertension was associated with a 35% increase in cardiovascular complications.12 An increase in cardiovascular and cerebrovascular complications and renal failure has been reported in patients with DBP >110 mm Hg immediately before surgery.25 In contrast, patients with DBP <110 mm Hg do not appear to be at sig­ nificantly increased risk.26 The relationship of systolic hypertension to surgical risk is less certain. During induction of anesthesia for surgery, a sympathetic reaction can result in a 20 to 30 mm Hg increase in BP among patients with normal BP.25 Lability in BP appears more likely in patients with poorly controlled hypertension, whereas studies have observed that patients with controlled hypertension respond simi­ larly to those who are normotensive.26 An elevated BP on the day of surgery may represent a situational (“white-coat hypertension”) response if there was evidence of controlled hypertension or normotension prior to surgery.27 Therefore, referring to patients’ baseline ambulatory BP is recommended to guide BP management. Without evidence for increased risk for perioperative complications in patients whose preoperative SBP/DBP is <180/110 mm Hg, there is little evidence to defer surgery, and the patient can be evaluated and BP can be controlled postopera­ tively or after discharge.12

5 Although few studies describe risks of withdraw­

ing BB in the perioperative period, longstanding evidence from other settings suggests that abrupt withdrawal of long-term BB is harmful and should be avoided.1,2,28 There are fewer data to describe whether short-term (1 to 2 days) perioperative use of BB, followed by rapid discontinuation, is harm­ ful.21,29 Importantly, abrupt discontinuation of cloni­ dine can result in rebound hypertension associated with norepinephrine surge.30

6 This guideline recommends against starting a BB on

the day of surgery in BB-naïve patients, particularly at high initial doses, in long-acting form, and if there are no plans for dose titration or monitoring for adverse events.4,15,16 Evidence has been summarized in at least

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