Consequences of continuing renin angiotensin aldosterone system antagonists in the preoperative period: a systematic review and meta-analysis

Abstract

BackgroundPatients who use angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) are prone to developing side effects like hypotension and even refractory hypotension during anesthesia use, and whether ACEIs/ARBs should be continued or discontinued in such patients remains debatable. The present systematic review and meta-analysis was conducted to clarify the consequences of continuing or withholding these drugs, especially with regards to the incidence of intraoperative hypotension, in patients who continue to use ACEIs/ARBs on the day of their scheduled surgery.MethodsStudies with data pertinent to the incidence of intraoperative hypotension during anesthesia use in patients who continued the use of ACEIs/ARBs on the day of their scheduled surgery were considered for inclusion.ResultsThirteen studies reporting on the incidences of intraoperative hypotension between patients who continued receiving ACEIs/ARBs and those who did not on the day of their surgical procedure were included. The pooled effects showed that hypotension during anesthesia was more likely to develop in patients who continued to take ACEIs/ARBs when compared to those who did not (RR = 1.41, 95% CI: 1.21–1.64). However, there were no significant differences between these groups of patients with regards to postoperative complications including ST-T abnormalities, myocardial injury, myocardial infarction, stroke, major adverse cardiac events, acute kidney injury, or death (RR = 1.25, 95% CI: 0.76–2.04). The differences remained similar in subgroup analyses and sensitivity analyses.ConclusionsNo sufficient available evidence to recommend discontinuing ACEIs/ARBs on the day of surgery was found in this literature review and meta-analysis. However, anesthetists should be cautious about the risk for intraoperative hypotension in patients chronically receiving ACEIs/ARBs, and should know how to treat it effectively.

Renin–angiotensin system blocker use and the risk of acute kidney injury after colorectal cancer surgery: a population-based cohort study

“…The debate of whether ACE-I/ARB use is potentially harmful or beneficial on outcomes after non-cardiac surgery is ongoing, due to conflicting results 14 47. The conflicting results may be due to the heterogeneity of the methodology across the studies.…”

Angiotensin axis blockade, acute kidney injury, and perioperative morbidity in patients undergoing colorectal surgery

“…Several meta-analyses have been performed to analyze the safety and feasibility of continuing ACEi/ARB in the perioperative period, [3,16,17] but none have specifically addressed the colorectal surgery population. In the most recent of these meta-analyses, ACEi/ARB use on the morning of noncardiac surgery caused more intraoperative hypotension compared to patients foregoing their morning antihypertensive dose.…”

Pre‐operative cardiac optimisation: a directed review

“…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 .…”

“…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 . In patients on chronic treatment, it is reasonable to continue them under supervision (Class IIa recommendation) .…”