To Hold or Not to Hold: ACE Inhibitors and ARBs in Perioperative Care

16 May 2023 • A randomized trial has addressed holding versus continuing ACE inhibitors and ARBs perioperatively. The study, published in Annals of Internal Medicine, compared the effects of hypotension-avoidance versus hypertension-avoidance strategies on major vascular complications after noncardiac surgery.

WHAT IS ALREADY KNOWN ON THIS TOPIC Among patients having noncardiac surgery, perioperative hemodynamic abnormalities are associated with vascular complications. Uncertainty remains about what intraoperative blood pressure to target and how to manage long-term antihypertensive medications perioperatively. Some clinicians recommend that patients stop taking ACE inhibitors and ARBs preoperatively due to concerns regarding intra-op hypotension & increased risk of adverse events when the drugs are continued until the time of surgery.

WHAT THIS STUDY ADDS In the unblinded POISE-3 trial, investigators randomized ≈7500 patients with hypertension (72% of whom were taking ACE inhibitors or ARBs) at 110 hospitals in 22 countries to either of the following: Hypotension avoidance: ACE inhibitors, ARBs, and direct renin inhibitors were held from the night before surgery until day 3 after surgery, intraoperative mean arterial pressure (MAP) was maintained at >80 mm Hg, and other blood pressure medications were added when systolic blood pressure was >130 mm Hg postoperatively.

Hypertension avoidance: Patients received all their usual antihypertensive medications preoperatively, including on the morning of surgery, and postoperatively, and intraoperative MAP was maintained at >60 mm Hg.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY Significantly fewer patients in the hypotension-avoidance group than in the hypertension-avoidance group developed intraoperative hypotension that required medical intervention (23% vs. 28%). No difference was noted in the 30-day composite outcome of vascular death, nonfatal myocardial injury, stroke, and cardiac arrest (14% in each group) or in any individual outcome within the composite.

The researchers conclude that in patients having noncardiac surgery, hypotension-avoidance and hypertension-avoidance strategies resulted in a similar incidence of major vascular complications.

Source: Annals of Internal Medicine | Read full story

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