AHA/ACC Guidelines provide the most current framework for perioperative cardiovascular medication management in noncardiac surgery (NCS), emphasizing individualized, risk-stratified decision-making.
Beta-Blockers
Continue in patients already on stable doses (Class I recommendation).
Abrupt discontinuation is harmful and should be avoided-risks rebound hypertension, tachycardia, and ischemia.
Initiate if indicated (e.g., high-risk surgery + ≥3 RCRI factors), but start ≥1–2 weeks before surgery, not on the day of — evidence shows harm when started acutely (POISE trial).
Target HR 60–80 bpm and SBP >100 mmHg preoperatively.
Do not initiate on the day of surgery — the POISE trial demonstrated that high-dose metoprolol started immediately preoperatively increased stroke (1.0% vs 0.5%) and all-cause mortality (3.1% vs 2.3%).
If a new indication for beta-blockade exists, initiation ≥7 days before surgery is recommended to allow dose titration and tolerability assessment (Class IIb).
Statins
Continue in patients already on statins (Class I).
Continue perioperatively — abrupt discontinuation is associated with increased cardiovascular events.
Initiate if the patient has an indication (vascular surgery, CAD, high risk) — ideally start ≥1 week before surgery.
Use long-acting formulations (e.g., rosuvastatin, atorvastatin) for better coverage if NPO.
Observational data consistently show lower perioperative mortality with statin use (1.8% vs 2.3%).
Initiate perioperatively in statin-naïve patients who meet standard ASCVD criteria for statin therapy, with the intention of long-term use (Class I).
The benefit of short-term perioperative loading remains uncertain based on the LOAD trial.
RAAS Inhibitors (ACE Inhibitors / ARBs)
In patients taking RAASi for hypertension undergoing elevated-risk NCS, omission 24 hours before surgery may be considered to reduce intraoperative hypotension (Class IIb).
The Stop-or-Not trial found no difference in the composite of mortality and postoperative complications between continuation and discontinuation, though continuation increased intraoperative hypotension.
A meta-analysis of 9 RCTs confirmed reduced intraoperative hypotension with discontinuation without differences in MACE, mortality, or AKI.
In patients taking RAASi for HFrEF, continuation is reasonable (Class IIa).
These patients were largely excluded from the discontinuation trials.
Antiplatelet Agents
Aspirin for primary prevention: Generally discontinue ≤7 days before surgery.
The POISE-2 trial showed no reduction in death or MI with routine perioperative aspirin but increased major bleeding (4.6% vs 3.8%).
Aspirin for secondary prevention: The ACCP suggests continuation over interruption for non-cardiac surgery is a conditional recommendation, though this may be modified for very high-bleeding-risk procedures (intracranial surgery).
P2Y₁₂ inhibitors: Stop clopidogrel 5 days, ticagrelor 3–5 days, and prasugrel 7 days before surgery.
Patients with coronary stents: Elective NCS should be delayed at least 30 days after bare-metal stent and 3–6 months (ideally 6–12 months) after drug-eluting stent placement.
Dual antiplatelet therapy management requires cardiology consultation.
Anticoagulants
The following table summarizes timing of perioperative interruption based on ACCP and AHA/ACC guidance:
Bridging anticoagulation with heparin is generally not recommended for most patients on oral anticoagulants for atrial fibrillation.
It should be reserved selectively for those at highest thrombotic risk (e.g., mechanical mitral valves, recent VTE within 3 months).
Other Considerations
SGLT2 inhibitors should be discontinued 3–4 days before surgery to minimize the risk of perioperative euglycemic ketoacidosis.
Clonidine should not be initiated perioperatively, but chronic clonidine should be continued to avoid rebound hypertension.
ACE Inhibitors / ARBs
Controversial — most guidelines now recommend holding on the morning of surgery -especially for non-heart-failure, hypertension-only indications.
Associated with refractory intraoperative hypotension if continued. Resume within 48 hours postoperatively once hemodynamically stable. Continue if used for HFrEF or recent MI where stopping carries higher risk — individualize.
Antiplatelet Agents (Aspirin / P2Y12 inhibitors)
Aspirin (primary prevention) Hold 7–10 days prior Aspirin (secondary prevention / CAD)|Generally continue In high risk Clopidogrel / Ticagrelor / Prasugrel|Hold 5–7 days prior Dual antiplatelet (post-DES) Do not stop without cardiology input-Delay surgery if possible
For bare metal stents (BMS): delay elective surgery ≥30 days. For drug-eluting stents (DES): delay elective surgery ≥6 months Premature discontinuation risks in-stent thrombosis — potentially catastrophic.
Anticoagulants (Warfarin / DOACs)
Warfarin: Hold 5 days before surgery; check INR day before. Bridging with LMWH: only for high thrombotic risk (e.g., mechanical mitral valve, AF with prior stroke, VTE within 3 months). BRIDGE trial showed bridging not beneficial for most AF patients.
DOACs (Apixaban, Rivaroxaban, Dabigatran, Edoxaban):
Hold 2 days (2–4 days for dabigatran if CrCl <50) before high-bleeding-risk procedures.
Hold 1 day before low-bleeding-risk procedures. No bridging needed in most cases.
Resume 24–72 hours postoperatively depending on hemostasis.
Antiarrhythmics
Continue amiodarone, digoxin, and other antiarrhythmics perioperatively in general.
Monitor digoxin levels and electrolytes (hypokalemia increases toxicity risk).
Ensure electrolyte optimization (K⁺, Mg²⁺) before surgery.
Diuretics
Generally hold on the morning of surgery to avoid hypovolemia and electrolyte disturbances.
Exception: continue if needed for acute decompensated heart failure.
Correct hypokalemia preoperatively.
Nitrates / Calcium Channel Blockers
Continue perioperatively in most cases. CCBs useful for rate control and anti-ischemic effect. IV nitrates available if oral administration not possible.
Key Guiding Principles Never abruptly stop beta-blockers or statins.
Consult cardiology before stopping dual antiplatelet therapy post-stent.
Individualize ACEi/ARB decisions based on indication (HTN vs. HFrEF).
Timing of DOAC cessation depends on renal function and bleeding risk of the procedure.
Always weigh thrombotic vs. bleeding risk — surgery type, patient comorbidities, and urgency all matter.