Written by Peter Liu
Spoon Feed
There was no difference in clinical outcomes between holding or continuing ACE inhibitor/angiotensin receptor blocker (ACEi/ARB) therapy in perioperative management prior to major noncardiac surgery.
Synopsis
The “Stop-or-Not” randomized trial investigated the continuation versus discontinuation of renin-angiotensin system inhibitors (RASIs) prior to major noncardiac surgery. Among 2,222 patients across 40 French hospitals, the primary composite outcome of all-cause mortality and major postoperative complications at 28 days occurred in 22% of both the discontinuation (n=1,115) and continuation (n=1,107) groups (risk ratio 1.02; P=0.85), showing no significant difference. However, intraoperative hypotension occurred more frequently and lasted longer in the continuation group (54% vs. 41%; risk ratio 1.31; P<0.001). Despite increased hypotension, continuation did not result in worse clinical outcomes. These findings support either strategy as safe, with discontinuation potentially reducing intraoperative hypotension risks. (AI-generated)
To hold or not to hold? A hospitalist’s soliloquy
The decision to hold or continue ACEi/ARB therapy in major noncardiac surgery is probably much ado about nothing. Several high-quality studies have shown increased incidence of perioperative hypotension with continuation of these medications, including the current “Stop-or-Not” trial. However, RCTs focused on postoperative hypertension have shown it to be tradeoff to holding ACEi/ARB (for example, the SPACE trial). These competing factors appear to be in the balance for most patients, which is why several RCTs have now shown similar postoperative outcomes regardless of the decision on ACEi/ARB hold (e.g. POISE-3 trial). Results on acute kidney injury have been similar in trials where this has been measured. In fact, even for cardiac surgery, with cardiopulmonary bypass, holding ACEi/ARB remains controversial, though common practice is to hold these medications in this setting due to concerns for vasoplegia and shock post-bypass. My own management of inpatient perioperative ACEi/ARB remains patient-centered. If severe perioperative hypertension is likely, medication side effect is unlikely, and the anesthesiology team is comfortable with the plan, I’ll usually continue the ACEi/ARB through the surgery.
Source
Continuation vs Discontinuation of Renin-Angiotensin System Inhibitors Before Major Noncardiac Surgery: The Stop-or-Not Randomized Clinical Trial. JAMA. 2024 Sep 24;332(12):970-978. doi: 10.1001/jama.2024.17123. PMID: 39212270
