Science, Medicine, and the Anesthesiologist

The impact of preoperative administration of renin-angiotensin system inhibitors (RASIs; angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) on intra- and postoperative outcomes remains a controversial topic given a lack of large-scale randomized studies. This large clinical trial (40 French centers; 2018 to 2023) randomized patients treated with a RASI for at least 3 months scheduled for major noncardiac surgery to either continuation until the day of surgery (n = 1,107) or to discontinuation 48 h before surgery (n = 1,115). The primary outcome was a composite of all-cause mortality and major postoperative complications by 28 days after surgery. Secondary outcomes included intraoperative, acute kidney injury; postoperative organ failure; and hospital/intensive care unit lengths of stay by 28 days after surgery. Of 2,222 patients (mean ± SD age, 67 ± 10 yr; 65% male), 46% were receiving angiotensin-converting enzyme inhibitors and 54% angiotensin receptor blockers. There was no significant difference in the primary outcome between the continuation and discontinuation groups (22% in each; risk ratio, 1.02 [95% CI, 0.87 to 1.19]; P = 0.85) nor in the prevalence of intraoperative hypotension (41% discontinuation vs. 54% continuation; risk ratio, 1.31 [95% CI, 1.19 to 1.44]). Likewise, no differences occurred in other study outcomes.

Take home message: This large, multicenter, randomized trial of continuation versus discontinuation of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in patients undergoing major noncardiac surgery did not demonstrate significant differences between groups in either mortality, major postoperative complications by 28 days, or intraoperative hypotension.