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Take It or Leave It: A Meta-analysis of Perioperative ACE Inhibitors and ARBs

Nathan, Naveen MD

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doi: 10.1213/ANE.0000000000003686
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The continuation of ACE inhibitors and angiotensin receptor blockers perioperatively has been associated with intraoperative hypotension. To date, it has remained unclear whether definitive outcomes emerge from the decision to withhold them on the morning of surgery. In this issue, Hollmann et al offer a systematic review and meta-analysis pooling roughly 6000 patients across 9 studies in the noncardiac surgical population that either continued their medication or had it withheld. The results substantiate the association of intraoperative hypotension and continuation of ACE-I/ARBs. No differences in mortality, cardiac events, stroke, acute kidney injury, or length of stay were found between the 2 groups. However, limitations of this analysis include lack of uniformity of the definitions of hypotension, inconsistent anesthetic regimens, and several other elements that reduce the power to elucidate statistical significance in outcomes. The reader is encouraged to review this article for further depth of understanding.

ACC/AHA indicates American College of Cardiology/American Heart Association; ACE-I, angiotensin-converting enzyme inhibitor; AKI, acute kidney injury; ARB, angiotensin receptor blocker; CCS, Canadian Cardiovascular Society; CVA, cerebrovascular accident; ESC/ESA, European Society of Cardiology/European Society of Anaesthesiology; MACE, major adverse cardiac event.


1. Hollmann C, Fernandes NL, Biccard BM. A systematic review of outcomes associated with withholding or continuing angiotensin-converting enzyme inhibitors and angiotensin receptor blockers before noncardiac surgery. Anesth Analg. 2018;127:678–687.
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