1/13/2017 ShouldWeWithholdACEInhibitorsJustBeforeNoncardiacSurgery?

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SUMMARYANDCOMMENT|GENERALMEDICINE

INFORMING PRACTIC

January12,2017

ShouldWeWithholdACEInhibitorsJustBeforeNoncardiacSurgery?
AllanS.Brett,MDreviewingRoshanovPSetal.Anesthesiology2017Jan.

Inanobservationalstudy,withholdingangiotensinconvertingenzymeinhibitorswasassociatedwithfeweradverseevents.

Forpatientswhotakeangiotensinconvertingenzyme(ACE)inhibitorsandundergononcardiacsurgery,someobservationalstudiessuggestthatcontinuingtheACE
inhibitorsonthemorningofsurgeryisassociatedwithexcessriskforintraoperativehypotension.However,theevidenceisnotdecisive,andthe2014American
CollegeofCardiology/AmericanHeartAssociationguidelineonmanagementofpatientsundergoingnoncardiacsurgeryconcludesthatcontinuationofACEinhibitors
orangiotensinreceptorblockers(ARBs)perioperativelyisreasonable(Circulation2014130:e278).

Now,researchershaveaddressedthisissueusingdatafromaprospectivecohortstudyofpatients(age,45)whounderwentnoncardiacsurgeryandrequired
overnighthospitaladmission.Among4802patientswhousedACEinhibitorsorARBsroutinely,74%tookthedrugduringthe24hoursbeforesurgerythedrugwas
withheldintheremaining26%.Thefollowingoutcomeswerenoted:

Theprimarycompositeoutcome(death,stroke,ormyocardialinjurydefinedbyperioperativeriseintroponinlevel)occurredin12.0%ofpatientswhoseACE
inhibitororARBwaswithheldandin12.9%ofthosewhosedrugwascontinuedafteradjustmentforpotentiallyconfoundingvariables(includingpreoperative
bloodpressureanduseofotherantihypertensivedrugs),therelativeriskforthisoutcomewassignificantlylowerinthedrugwithheldgroup(RR,0.82P=0.01).

Incidenceofintraoperativehypotensionwaslowerinthedrugwithheldgroupthaninthedrugcontinuedgroup(23.3%vs.28.6%)inadjustedanalyses,relative
riskwassignificantlylowerinthedrugwithheldgroup(RR,0.80P<0.001).

ClinicalandsurgicalfactorswerenotassociatedsubstantiallywithcontinuingversuswithholdingACEinhibitorsorARBsthus,mostdecisionstowithholdthe
drugslikelywerearbitraryandbasedonclinicianpreference.

COMMENT
Thisanalysisdoesn'tcarrytheauthorityofarandomizedtrial,buttheauthors'conclusionthatweshouldconsiderwithholdingACEinhibitorsandARBs
beforenoncardiacsurgeryisreasonable.Theynotethatanesthesiarelatedbluntingofsympatheticvasculartonemightincreaserelianceontherenin
angiotensinsystemtomaintainbloodpressureintraoperatively.

EDITORDISCLOSURESATTIMEOFPUBLICATION

DisclosuresforAllanS.Brett,MDattimeofpublication

Nothingtodisclose

CITATION(S):

RoshanovPSetal.WithholdingversuscontinuingangiotensinconvertingenzymeinhibitorsorangiotensinIIreceptorblockersbeforenoncardiacsurgery:Ananalysis
oftheVascularEventsinNoncardiacSurgeryPatientsCohortEvaluationprospectivecohort.Anesthesiology2017Jan126:16.
(http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2572372)

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