title: Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort.
abstract: The effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before noncardiac surgery is unknown.
  
  
  
  In this international prospective cohort study, the authors analyzed data from 14,687 patients (including 4,802 angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users) at least 45 yr old who had in-patient noncardiac surgery from 2007 to 2011. Using multivariable regression models, the authors studied the relationship between withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and a primary composite outcome of all-cause death, stroke, or myocardial injury after noncardiac surgery at 30 days, with intraoperative and postoperative clinically important hypotension as secondary outcomes.
  
  
  
  Compared to patients who continued their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, the 1,245 (26%) angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users who withheld their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in the 24 h before surgery were less likely to suffer the primary composite outcome of all-cause death, stroke, or myocardial injury (150/1,245 [12.0%] vs. 459/3,557 [12.9%]; adjusted relative risk, 0.82; 95% CI, 0.70 to 0.96; P = 0.01) and intraoperative hypotension (adjusted relative risk, 0.80; 95% CI, 0.72 to 0.93; P < 0.001). The risk of postoperative hypotension was similar between the two groups (adjusted relative risk, 0.92; 95% CI, 0.77 to 1.10; P = 0.36). Results were consistent across the range of preoperative blood pressures. The practice of withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers was only modestly correlated with patient characteristics and the type and timing of surgery.
  
  
  
  Withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. A large randomized trial is needed to confirm this finding. In the interim, clinicians should consider recommending that patients withhold angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 24 h before surgery.
authors: From the London Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada (P.S.R.); Departments of Medicine (B.R., A.P., O.S., E.D., E.P.B.-C., G.H.G., F.K.B., V.T., A.W., F.A.S., Z.P., P.J.D.), Clinical Epidemiology and Biostatistics (B.R., E.D., E.P.B.-C., G.H.G., Y.L.M., A.W., P.J.D.), and Anesthesiology (Y.L.M., J.P., K.E.R.), McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada (E.D., E.P.B.-C., Y.L.M., F.K.B., A.T., M.K., B.D., P.J.D.); Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S.); Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin (R.D.S.); and Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (E.N.S., E.E.M.).
authors: Pavel S
authors: PS
authors: Roshanov
authors: Bram
authors: B
authors: Rochwerg
authors: Ameen
authors: A
authors: Patel
authors: Omid
authors: O
authors: Salehian
authors: Emmanuelle
authors: E
authors: Duceppe
authors: Emilie P
authors: EP
authors: Belley-Côté
authors: Gordon H
authors: GH
authors: Guyatt
authors: Daniel I
authors: DI
authors: Sessler
authors: Yannick
authors: Y
authors: Le Manach
authors: Flavia K
authors: FK
authors: Borges
authors: Vikas
authors: V
authors: Tandon
authors: Andrew
authors: A
authors: Worster
authors: Alexandra
authors: A
authors: Thompson
authors: Mithin
authors: M
authors: Koshy
authors: Breagh
authors: B
authors: Devereaux
authors: Frederick A
authors: FA
authors: Spencer
authors: Robert D
authors: RD
authors: Sanders
authors: Erin N
authors: EN
authors: Sloan
authors: Erin E
authors: EE
authors: Morley
authors: James
authors: J
authors: Paul
authors: Karen E
authors: KE
authors: Raymer
authors: Zubin
authors: Z
authors: Punthakee
authors: P J
authors: PJ
authors: Devereaux
mesh_terms: D000368:Aged; D057911:Angiotensin Receptor Antagonists / Q000008:administration & dosage*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007022:Hypotension / Q000453:epidemiology; D038622:Internationality; D007431:Intraoperative Complications / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology*; D011446:Prospective Studies; D013514:Surgical Procedures, Operative; D028761:Withholding Treatment / Q000706:statistics & numerical data*
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors