Influence of Angiotensin-Converting Enzyme Inhibitors on Hypotension after Anesthetic Induction. Is the Preoperative Discontinuation of this Drug Necessary?

Costa, Verônica Vieira da; Caldas, Alexandre Curvelo; Nunes, Luiz Guilherme Nadal; Beraldo, Paulo Sérgio Siebra; Saraiva, Renato Ângelo

doi:10.1016/s0034-7094(09)70095-9

Cited by 8 publications

(6 citation statements)

References 13 publications

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“…There is an increased risk of intra‐operative hypotension when they are continued and clinically‐significant hypotension is independently associated with increased myocardial infarction, stroke and death, leading to the recommendation towards withholding them at least 24 h before major surgery . However, other studies show conflicting results with no sufficient available evidence to recommend discontinuing the drugs on the day of surgery . Anaesthetists should be aware of the potential risk of intra‐operative hypotension in patients receiving the drugs and be prepared to manage it .…”

Section: Hypertensionmentioning

confidence: 99%

Pre‐operative cardiac optimisation: a directed review

Lee

Tsai

et al. 2019

Anaesthesia

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Cardiac events remain the leading cause of peri-operative morbidity and mortality, and patients undergoing major surgery are exposed to significant risks which may be preventable and modifiable. Proper assessment and management of various cardiac conditions in the peri-operative period by anaesthetists can markedly improve patient safety, especially in high-risk patient populations. This involves understanding and applying current evidence-based practice and international guidelines on the main aspects of cardiac optimisation, including management of patients with hypertension, chronic heart failure, valvular heart diseases and cardiac implantable electronic devices. Peri-operative management of antihypertensive drugs in keeping with the current best evidence is discussed. Pre-operative cardiac risk assessment and cardiac biomarkers can be used to help predict and quantify peri-operative adverse cardiac events. There is an increasing need for anaesthetist-led services, including focused transthoracic echocardiography and management of implantable cardiac electronic devices. Anaesthetists should be encouraged to play a proactive role in pre-operative risk stratification and make timely multidisciplinary referrals if necessary. A personalised approach to pre-operative cardiac optimisation enables a safer peri-operative journey for at-risk patients undergoing major surgery.

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Section: Hypertensionmentioning

confidence: 99%

Pre‐operative cardiac optimisation: a directed review

Lee

Tsai

et al. 2019

Anaesthesia

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“…There are multiple reports 3,6,11,4,17,19 of different approaches to treating severe hypotension refractory to fluid administration associated with AAB agents. There are no summary guidelines for the management of this relatively common occurrence.…”

Section: Reviewmentioning

confidence: 99%

“…4 There is an ongoing debate as to whether ACEIs and ARBs should be discontinued before surgery. 2,3,[5][6][7][8][9] Although omitting these agents before general anesthesia may avoid hypotension, 3,8,10 some argue that their discontinuation is not required because the associated hypotension is easily treatable 6,11 and subsequent hypertension may occur perioperatively requiring antihypertensive therapy. 9 Furthermore, the discontinuation of ACEIs and ARBs might remove the potential beneficial effect of AAB on myocardial protection 9, [12][13][14] Adding to this debate, preoperative therapy with ACEIs in cardiac surgery 5 and ACEIs and ARBs in vascular surgery 15 have been found to be associated with an increased risk of mortality.…”

mentioning

confidence: 99%

Management of Hypotension Associated With Angiotensin-Axis Blockade and General Anesthesia Administration

Mets

2013

Journal of Cardiothoracic and Vascular Anesthesia

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“…Nevertheless, the current evidence does not provide a definitive answer regarding whether ACEIs/ARBs should be continued or withheld in the perioperative setting. While some studies showed that continuation of ACEIs/ARBs was associated with an increased risk of intraoperative hypotension (11)(12)(13)(14)(15), other studies argued that different ACEIs/ARBs management strategies did not affect perioperative hemodynamic stability or postoperative outcomes (16)(17)(18)(19). To date, there is no welldesigned randomized controlled trial with adequate power to assess the perioperative risks and benefits of ACEIs/ARBs.…”

Section: Introductionmentioning

confidence: 99%

Withholding vs. Continuing Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers Before Non-cardiac Surgery in Older Patients: Study Protocol for a Multicenter Randomized Controlled Trial

et al. 2021

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Background: Older hypertensive adults are at increased risk for postoperative morbidity and mortality. As first line antihypertensive drug therapy, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) have many beneficial effects. However, the use of ACEIs/ARBs in the perioperative period remains controversial. This study aims to determine the effects of withholding vs. continuing ACEIs/ARBs before non-cardiac surgery on perioperative hypotension and postoperative outcomes in older patients.Methods: In this multicenter, randomized, double-blind, placebo-controlled trial, a total of 2036 patients aged 60–80 years undergoing non-cardiac surgical procedures will be randomly assigned, in a 1:1 ratio, to receive oral ACEIs/ARBs (the ACEIs/ARBs continued group) or inactive placebos (the ACEIs/ARBs withheld group) on the morning of surgery. For both groups, the ACEIs/ARBs will be continued from the first postoperative day. The primary outcome measure is the incidence of perioperative hypotensive events, defined as mean blood pressure (MBP) < 65 mmHg or ≥30% reduction in MBP from baseline during surgery and in a post-anesthesia care unit. The secondary outcomes include duration of perioperative hypotension, intraoperative use of fluids and vasopressors, hypotensive events within postoperative 3 days, and perioperative neurocognitive disorders, major adverse cardiocerebral events (a composite outcome of stroke, coma, myocardial infarction, heart block, and cardiac arrest), and mortality within 30 days after surgery.Discussion: The results of this trial will offer an evidence-based perioperative ACEIs/ARBs therapy for older hypertensive adults undergoing non-cardiac surgery.Study Registration: This study is approved by the Medical Ethics Committee of The First Affiliated Hospital of Soochow University (Approval No. 2020-077-1) and by the institutional ethics review board of each participating center. This protocol is registered at the Chinese Clinical Trials Registry (ChiCTR2000039376).

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Influence of Angiotensin-Converting Enzyme Inhibitors on Hypotension after Anesthetic Induction. Is the Preoperative Discontinuation of this Drug Necessary?

Cited by 8 publications

References 13 publications

Pre‐operative cardiac optimisation: a directed review

Pre‐operative cardiac optimisation: a directed review

Management of Hypotension Associated With Angiotensin-Axis Blockade and General Anesthesia Administration

Withholding vs. Continuing Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers Before Non-cardiac Surgery in Older Patients: Study Protocol for a Multicenter Randomized Controlled Trial

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