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CLINICIAN REFERENCE

ACE inhibitors / ARBs / RAAS inhibitors

Management of renin–angiotensin–aldosterone system (RAAS) inhibitors depends on the indication and surgical risk.

Current guidance

AHA/ACC 2024 states that omission about 24 hours before elevated-risk non-cardiac surgery may help limit intraoperative hypotension in selected patients taking these medicines for hypertension with controlled blood pressure. For treatment of heart failure with reduced ejection fraction, continuation is considered reasonable, subject to clinical circumstances.

Evidence context

The Stop-or-Not trial (JAMA 2024) studied 2,222 adults receiving chronic ACE-inhibitor or ARB treatment before major non-cardiac surgery at 40 French hospitals. The primary 28-day composite outcome occurred in 22% of both the continuation and discontinuation groups (risk ratio 1.02, 95% CI 0.87–1.19). Intraoperative hypotension was more frequent with continuation: 54% versus 41%. The trial did not show a difference in its primary outcome in this population; it does not establish that both strategies are equally suitable for every patient or indication.

Indication matters

These medicines may be prescribed for hypertension, heart failure or kidney disease. The balance between hypotension and the consequences of interruption varies by indication. The Stop-or-Not result concerns ACE inhibitors and ARBs; it is not a direct trial of all heart-failure medicines, including ARNIs or mineralocorticoid receptor antagonists.

Practical application

  • Recording the indication as well as the medicine helps establish the reason for continuing or interrupting it.
  • If interruption is agreed, a clear last-dose instruction can avoid uncertainty.
  • Potential intraoperative hypotension is relevant to the anaesthetic plan, particularly when treatment is continued.
  • A resumption plan can help avoid unintended prolonged interruption. Volume status, blood pressure, renal function and the original indication inform when restarting is appropriate.

Sources