Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery

Abstract

Background The effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before noncardiac surgery is unknown. Methods In this international prospective cohort study, the authors analyzed data from 14,687 patients (including 4,802 angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users) at least 45 yr old who had in-patient noncardiac surgery from 2007 to 2011. Using multivariable regression models, the authors studied the relationship between withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and a primary composite outcome of all-cause death, stroke, or myocardial injury after noncardiac surgery at 30 days, with intraoperative and postoperative clinically important hypotension as secondary outcomes. Results Compared to patients who continued their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, the 1,245 (26%) angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users who withheld their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in the 24 h before surgery were less likely to suffer the primary composite outcome of all-cause death, stroke, or myocardial injury (150/1,245 [12.0%] vs. 459/3,557 [12.9%]; adjusted relative risk, 0.82; 95% CI, 0.70 to 0.96; P = 0.01) and intraoperative hypotension (adjusted relative risk, 0.80; 95% CI, 0.72 to 0.93; P < 0.001). The risk of postoperative hypotension was similar between the two groups (adjusted relative risk, 0.92; 95% CI, 0.77 to 1.10; P = 0.36). Results were consistent across the range of preoperative blood pressures. The practice of withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers was only modestly correlated with patient characteristics and the type and timing of surgery. Conclusions Withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. A large randomized trial is needed to confirm this finding. In the interim, clinicians should consider recommending that patients withhold angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 24 h before surgery.

When the pressure drops: A case of vasoplegia during a structural heart intervention

“…Optimal timing for perioperative discontinuation of RASi therapy has also not been elucidated. While holding RASi on the day of surgery appears to decrease morbidity and mortality, 23 prospective trials to guide recommendations are lacking.…”

Role of vasopressin in current anesthetic practice

“…By blunting sympathetic nervous activity on vascular tone, general anesthesia with most anesthetics may increase reliance on the renin-angiotensin and vasopressin systems to maintain blood pressure. ACEIs and angiotensin II receptor antagonists (AIIRAs) are used widely as first-line therapy for arterial hypertension [39]. In patients with long-term use of ACEIs/AIIRAs, intra-operative hypotension associated with general anesthesia may be refractory to treatment with norepinephrine, phenylephrine, and ephedrine [39].…”

“…ACEIs and angiotensin II receptor antagonists (AIIRAs) are used widely as first-line therapy for arterial hypertension [39]. In patients with long-term use of ACEIs/AIIRAs, intra-operative hypotension associated with general anesthesia may be refractory to treatment with norepinephrine, phenylephrine, and ephedrine [39]. In those whose sympathetic and reninangiotensin systems have been blunted by general anesthesia and ACEIs/AIIRAs, TP (IV 1–2 mg) or AVP (IV 2–3 U) is an effective vasopressor if they are refractory to common adrenergic vasopressors [404142].…”

Association of renin angiotensin antagonists with adverse perioperative events in patients undergoing elective orthopaedic surgery: a case–control study

“…An observational study on orthopaedic patients demonstrated significant increase in post‐operative acute kidney injury (AKI) after adjusting for other confounders in patients prescribed RAA . A retrospective analysis of a large prospective cohort ( n = 4802) of patients taking RAA routinely showed 18% reduction in adjusted risk of intraoperative hypotension, cardiovascular events and death in those who withheld their medication prior to surgery . Patients undergoing cardiothoracic surgery or vascular surgery appear to have higher mortality risk, whereas outcomes in non‐cardiac surgery are less clear.…”

“…7 A retrospective analysis of a large prospective cohort (n = 4802) of patients taking RAA routinely showed 18% reduction in adjusted risk of intraoperative hypotension, cardiovascular events and death in those who withheld their medication prior to surgery. 4 Patients undergoing cardiothoracic surgery 8 or vascular surgery 9 appear to have higher mortality risk, whereas outcomes in non-cardiac surgery are less clear. In contrast, a randomised trial of 526 patients comparing outcomes in those who continued or discontinued RAA prior to surgery showed no difference in adverse events, 10 a finding replicated in another non-randomised study.…”