A resident working with you in the preoperative evaluation clinic is asking whether to hold angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for noncardiac surgery in patients with a history of hypertension on the morning of surgery. According to a recent study, which of the following outcomes is MOST likely in hypertensive patients who continued these medications compared with those who held them preoperatively?
(A) Severe intraoperative hypotension requiring intravenous pressor infusion X
(B) Intraoperative hypotension requiring more intravenous pressor boluses X
(C) Similar risk of intraoperative hypotension ✔
Read the discussion below.
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Evidence prior to 2014 suggested that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) taken immediately before elective surgery (versus holding them on the day of surgery) was associated with intraoperative hypotension and, in some cases, severe hypotension refractory to common intravenous vasopressors. As conflicting data became available, many centers elected to continue ACEIs and ARBs on the day of surgery, especially for patients with heart failure and poorly controlled hypertension. The American College of Cardiology and American Heart Association (ACC/AHA) guidelines on preoperative cardiovascular evaluation of patients undergoing noncardiac surgery—last updated in 2014—state that continuation of ACEIs or ARBs perioperatively is “reasonable,” and if these drugs “are held before surgery, it is reasonable to restart as soon as clinically feasible postoperatively.”
To further clarify the ACC/AHA guidelines, a retrospective cohort analysis compared the severity of intraoperative hypotension between hypertensive patients who took an ACEI or ARB on the day of elective noncardiac surgery and those who held them. All 349 adults included in the analysis received general anesthesia. There were 153 patients who took an ACEI or ARB on the day of surgery and 196 who held them. No group differences were found in mean age (65 years), body mass index (31 kg/m2), and American Society of Anesthesiologists physical status (2.7). Intraoperative blood pressure (BP) was recorded preinduction and for 15 minutes post induction.
Anesthesia induction medications and doses were similar between groups. Both groups had a decrease in systolic BP and diastolic BP post induction. However, no group differences were found in the change in systolic BP, diastolic BP, or heart rate. Moreover, there was no difference in pressor infusion or bolus use between groups. Finally, the occurrence of hypotension was similar between patients who took ACEIs and those who took ARBs.
This study did not report on postoperative outcomes. Larger observational studies have been unable to consistently demonstrate that continuing ACEIs and ARBs on the day of surgery is independently associated with 30-day adverse outcomes such as death, myocardial infarction, and renal failure. However, these studies generally suggest that ACEIs and ARBs taken on the day of surgery are associated with a greater incidence of intraoperative hypotension.
In summary, this study demonstrated that postinduction hypotension was not associated with continuation of ACEIs or ARBs on the day of elective noncardiac surgery. The authors did not provide the decision process that instructed patients to take or hold them, if such a process existed. Until prospective studies can be conducted, recommendations for continuing ACEIs and ARBs on the day of surgery remain specific to the patient (ie, severity of hypertension, heart failure) and procedure (ie, duration, expected blood loss).
- Yoon U, Setren A, Chen A, Nguyen T, Torjman M, Kennedy T. Continuation of angiotensin-converting enzyme inhibitors on the day of surgery is not associated with increased risk of hypotension upon induction of general anesthesia in elective noncardiac surgeries. J Cardiothorac Vasc Anesth. 2021;35(2):508-513. doi:10.1053/j.jvca.2020.01.005
- Fleisher LA, Fleischmann KE, Auerbach AD, et al; American College of Cardiology, American Heart Association. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77-e137. doi:10.1016/j.jacc.2014.07.944
- Lee SM, Takemoto S, Wallace AW. Association between withholding angiotensin receptor blockers in the early postoperative period and 30-day mortality: a cohort study of the Veterans Affairs Healthcare system. Anesthesiology. 2015;123(2):288-306. doi:10.1097/ALN.0000000000000739
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