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


OBJECTIVE
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.


METHODS
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.


METHODS
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.


RESULTS
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.
Rosenman
David J
DJ
Knowledge and Encounter Research Unit, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA. Rosenman.david@mayo.edu
McDonald
Furman S
FS
Ebbert
Jon O
JO
Erwin
Patricia J
PJ
LaBella
Matthew
M
Montori
Victor M
VM
D047228:Angiotensin II Type 1 Receptor Blockers / Q000008:administration & dosage* / Q000009:adverse effects; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D007022:Hypotension / Q000188:drug therapy / Q000503:physiopathology; D009203:Myocardial Infarction / Q000188:drug therapy / Q000503:physiopathology; D011300:Preoperative Care / Q000379:methods*; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D016896:Treatment Outcome
D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors