Perioperative management of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers

Abstract

Angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) reduce cardiac remodelling, fibrosis, and inflammation. High-risk surgical patients requiring non-cardiac surgery are frequently prescribed ACEIs or ARBs as first-line therapy for hypertension and other conditions, including heart failure, myocardial infarction (MI) and stroke, diabetes mellitus leading to diabetic nephropathy, etc. However, the continuation of ACEIs or ARBs in the perioperative period has been associated with an increased risk of intraoperative hypotension. The data on the perioperative management of these medications are limited. Consider, a 73-years-old woman with hypertension and type 2 diabetes having bilateral salpingo-oophorectomy for ovarian cancer. Her medications included ramipril, amlodipine, and oral hypoglycaemic agents. The ramipril was continued perioperatively, and besides transient but severe hypotension at induction of anaesthesia, the patient's course was unremarkable. The present case-based review discusses the current controversies surrounding the perioperative management of ACEIs and ARBs.