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The Risk of Hypertension after Preoperative Discontinuation of Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Antagonists in Ambulatory and Same-Day Admission Patients

Twersky, Rebecca S. MD, MPH*; Goel, Vasudha MD*; Narayan, Preeti MD*; Weedon, Jeremy PhD, MA, BS

doi: 10.1213/ANE.0000000000000076
Ambulatory Anesthesiology: Research Report

BACKGROUND: The continued use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II subtype I receptor antagonists (ARBs) medications in the preoperative period has been reported to be associated with intraoperative hypotension that can be unresponsive to pressor drugs. As a result, several investigators suggested discontinuation of these medications before scheduled surgery but did not report on unintended consequences that might result from discontinuation. We conducted a prospective, single-blind, randomized trial to observe the effect of the medications on preoperative arterial blood pressure recordings in patients presenting for ambulatory and same-day surgery.

METHODS: Six hundred forty-four patients presenting for ambulatory and same-day surgery were enrolled prospectively between 2006 and 2011 and randomly assigned to 2 groups based on continuation or discontinuation of ACEIs and ARBs. An intention-to-treat analysis was performed. The primary outcome was presence of hypertension (HTN) immediately before surgery. Secondary outcomes included surgical cancellations due to HTN, prolongation of hospitalization, adverse clinical events, and HTN in the postoperative period.

RESULTS: Data for 526 patients were analyzed. There were 262 patients in the discontinuation group and 264 patients in the continuation group. Discontinuation of ACEIs and ARBs on the day of surgery was not associated with increased prevalence of preoperative HTN (P = 0.775). The upper bound of a 95% confidence interval for the difference in prevalence of Stage 1 and 2 HTN between study arms indicates that discontinuation of study medication is unlikely to be associated with an increase in Stage 1 HTN of >4.8 percentage points and in Stage 2 HTN of no >5.8 percentage points. Discontinuation was not associated with an increase in postoperative HTN, with prolongation of hospitalization or with adverse clinical events.

CONCLUSIONS: Discontinuing ACEIs and ARBs in patients on the day of surgery did not result in a substantively increased incidence of pre- or postoperative HTN compared with patients who continued these medications on the day of surgery. The results provide an evidentiary basis for the safety of discontinuing ACEIs and ARBs on the day of surgery without increasing adverse hemodynamic outcomes.

From the *Department of Anesthesiology, and School of Public Health, SUNY Downstate Medical Center, Brooklyn, New York.

Vasudha Goel, MD, is currently affiliated with Medical Advanced Pain Specialists, Minneapolis, Minnesota.

Accepted for publication November 15, 2013.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Rebecca S. Twersky, MD, MPH, Department of Anesthesiology, Box 6, SUNY Downstate Medical Center, Brooklyn, NY 11203. Address e-mail to

© 2014 International Anesthesia Research Society