Clinical consequences of withholding versus administering renin‐angiotensin‐aldosterone system antagonists in the preoperative period

Abstract

BACKGROUND:Hospitalists involved in perioperative care either stop or continue until the day of surgery renin‐angiotensin‐aldosterone system antagonists (either angiotensin‐converting enzyme inhibitors [ACEI] or angiotensin II receptor subtype 1 antagonists [ARA]) in patients who use these agents chronically. This practice variation reflects uncertainty regarding the risks and benefits of either approach.PURPOSE:The purpose of this study was to assess the clinical consequences of preoperatively continuing versus withholding ACEI/ARAs in patients treated chronically with these agents.DATA SOURCES AND STUDY SELECTION:We comprehensively searched 7 major electronic databases, considered references from selected reviews, hand‐searched journals, and communicated with experts. We included randomized trials and observational studies.DATA EXTRACTION:We evaluated the relative risk (RR) of hypotension requiring vasopressors and of myocardial infarction in patients who did or did not receive an immediate preoperative dose of ACEI or ARA.DATA SYNTHESIS:Random‐effects meta‐analysis from 5 studies totaling 434 patients suggested that patients receiving an immediate preoperative ACEI/ARA dose were more likely (RR 1.50, 95% CI 1.15‐1.96) to develop hypotension requiring vasopressors at or shortly after induction of anesthesia. Sufficient data were not available to assess other outcomes.CONCLUSIONS:Preoperative administration of ACEI/ARAs increases intraoperative hypotension. The long‐term clinical consequences of continuing versus withholding preoperative ACEI/ARAs are unknown. This uncertainty stems in part from the absence to date of randomized trials designed specifically to examine patient‐important consequences of this decision. Journal of Hospital Medicine 2008;3:319–325. © 2008 Society of Hospital Medicine.

More hypotension in patients taking antihypertensives preoperatively during shoulder surgery in the beach chair position

“…8 Notably, the institutional standard of care for these patients was to instruct them to discontinue ACEI/ARA therapy the day of surgery, although the long-term impact of withholding ACEI/ARA therapy vs continuing the therapy on the day of surgery is unknown. 9 In our study, we also found more hypotensive episodes among ACEI/ARA patients also taking a diuretic vs patients on no antihypertensives. Measurement of blood pressure during procedures performed in the beach chair position remains controversial.…”

The Effect of Antihypertensive Class on Intraoperative Pressor Requirements During Carotid Endarterectomy

“…Currently there is debate whether to withhold these medications preoperatively. To address this debate, a number of small studies have been conducted to evaluate if patients taking chronic ACEI or ARBs experience hypotension and require more vasopressors than patients taking other antihypertensive medications during general anesthesia 6,7,9 . The major limitation of these studies is their small sample size and a large number of other antihypertensive drugs taken.…”

“…6,7,9 Some studies suggest formulating guidelines to withhold ACEI and ARBs preoperatively 5,8,[10][11][12] . However, few studies address the fact that patients with chronic hypertension are often taking multiple antihypertensive medications from different classes, which may interact and confound results, 13 and little data are available on the effect of the number and class of antihypertensive drug on intraoperative hypotension.…”

2014 ESC/ESA Guidelines on Non-cardiac Surgery: Cardiovascular Assessment and Management

“…Although continuation of ACEIs/ARBs until the day of surgery has been associated with an increased incidence of hypotension, 180 it is in general recommended that all heart-failure medications, such as ACE inhibitors, ARBs, and beta-blockers, be continued and that the patient's haemodynamic status be carefully monitored and give appropriate volume replacement when necessary. In patients considered susceptible to hypotension, transient discontinuation the day before surgery may be considered.…”