Combination antihypertensive therapy and anesthesia-induced hypotension: A prospective comparative observational study

Abstract

Perioperative hemodynamic instability is a major concern in hypertensive patients undergoing general anesthesia. Nearly 45% of these patients require dual antihypertensive therapy, yet the perioperative effects of specific drug combinations remain poorly defined. While single-agent effects are well documented, data on dual regimens are limited, particularly regarding hypotension duration and recovery. This study compared hemodynamic responses across five commonly used dual antihypertensive combinations. A prospective observational study was conducted in hypertensive patients aged 35–70 years (American society of anesthesiologist grading (ASA) II/III) on dual therapy scheduled for elective surgery. Patients were grouped into angiotensin II receptor blocker (ARB) + diuretic, angiotensin-converting enzyme inhibitor (ACEI) + diuretic, ACEI + calcium channel blocker (CCB), ARB + CCB, and CCB + β-blocker regimens. Hemodynamic parameters were recorded from induction to 30 minutes post-intubation. The primary outcome was hypotension duration; secondary outcomes included incidence of hypotension, vasopressor use, and heart rate (HR) response. Ninety-three patients were analyzed. Hypotension occurred in 77.4% overall, with no difference in incidence between groups ( P = 0.330). However, hypotension duration differed significantly ( P = 0.007), being longest with CCB + β-blocker (12.4 ± 8.1 minutes) and shortest with ACEI + CCB (3.6 ± 1.5 minutes; mean difference 8.7 minutes, 95% CI: 2.24–15.32, P = 0.003). Post-laryngoscopy HR rise was significantly more attenuated in ARB + CCB versus ARB + diuretic groups (mean difference 17 bpm, P = 0.017). While dual antihypertensive regimens show similar rates of hypotension, recovery duration varies significantly. CCB + β-blocker combinations are associated with prolonged hypotension, whereas ACEI + CCB regimens recover faster. These findings support individualized perioperative monitoring and drug-specific management strategies.