Recommendations on antihypertensives in the peri‐operative period: a reply

We thank Frank for her correspondence [1] on our guideline [2]. Management of medicines for heart failure in the peri-operative period was outside the scope of our guideline, but guidance for this does exist elsewhere [3]. The ‘STOP or NOT’ and ‘SPACE’ trials included very small numbers of participants with heart failure, and data to recommend a change in this patient group are limited. Most patients with heart failure with reduced ejection fraction have low blood pressure and therefore have the most to lose from stopping therapy, whilst patients with heart failure with preserved ejection fraction require different management. Continuation of antihypertensives is reasonable for most patients, but the evidence base in heart failure is weak. There are limited trial data to recommend changing the peri-operative approach to angiotensin receptor neprilysin inhibitors. We did not focus on this drug class as they are indicated primarily for heart failure. Other groups have discussed these drugs [4, 5] but have not recommended continuation in the peri-operative period, instead suggesting cessation 24-h pre-operatively and restarting as soon as practical in the postoperative period. In both cases, the level of evidence is ‘expert consensus’. Our approach is consistent with these bodies, and more research is needed before changing current practice. The renal inhibitor aliskiren is a hypertension treatment, but very unlikely to be used in patients in the UK. We do suggest an alternative approach to the other guidelines, and we base our advice on the 2024 British and Irish Hypertension position statement [6]. If pre-operative initiation of treatment is required, the patient will have a blood pressure of ≥160/100 mmHg and will therefore be likely to require more than one drug to achieve control. The recommendation to start a calcium channel blocker and an angiotensin receptor blocker avoids concerns regarding age and race because it jumps straight to step two of the National Institute for Health and Care Excellence guidance and British and Irish Hypertension position statement.