ACEi-ARBs and Hypotension After Induction

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Hold ACE-inhibitors (ACEi) or angiotensin receptor blockers (ARBs) in patients you know will need surgery. These drugs are not associated with mortality but are associated with, at times, profound, sustained hypotension after induction.

Why does this matter?
Many times, we admit patients who have a high likelihood of needing surgery in the near future.  Often we are asked to enter the patient's home medications or are asked if the patient may take home medications they have with them.  Most medications don't have a big impact, with the exception of anticoagulants.  Several studies have shown ACEi and ARBs are associated with profound bouts of hypotension in the OR.  This was a systematic review to look into whether this increased mortality or other adverse outcomes.

You got to have an ACEi in the hole...
This was a systematic review of 5 RCTs and 4 observational studies that looked at the differences when ACEi or ARBs were held the morning of non-cardiac surgery vs given on schedule.  In just over 6000 combined patients, 1816 patients held the med; 4206 gave them.  There was no mortality or major adverse coronary event difference between the groups.  There was also no difference in CHF, AKI, or CVA.  However, the odds of intraoperative hypotension was reduced 37% when ACEi and ARBs were held.  This wasn't a temporary drop after induction either.  Most were sustained periods of hypotension up to 60 minutes.  The application for us in the ED is that when we know patients are bound for the OR, hold ACEi or ARBs preoperatively.  Also, be more wary of hypotension after intubation in the ED when the patient's med list includes ACEi or ARBs.

A Systematic Review of Outcomes Associated With Withholding or Continuing Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Before Noncardiac Surgery.  Anesth Analg. 2018 Jan 29. doi: 10.1213/ANE.0000000000002837. [Epub ahead of print]

Peer reviewed by Thomas Davis, MD.

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