JAMA

ACE-inhibitors or ARBs before noncardiac surgery: To stop or not to stop?

September 23, 2024

Among patients undergoing major noncardiac surgery, continuation (vs. discontinuation) of renin-angiotensin system inhibitors (RASIs) before surgery didn’t result in a higher rate of post-op complications.

• The randomized Stop-or-Not trial included patients who were being treated with a RASI for ≥3 months and were scheduled to undergo major noncardiac surgery between January 2018 and April 2023 at 40 hospitals in France. Patients were randomized to continuation of RASIs (n=1,107) until the day of surgery or discontinuation of RASIs 48 hours prior to surgery (n=1,115). Primary outcome was a composite of all-cause mortality and major post-op complications within 28 days after surgery. Key secondary outcomes were episodes of hypotension during surgery, acute kidney injury, postoperative organ failure, and length of hospital and ICU stay during the 28 days after surgery.
• Of the 2,222 patients (mean age, 67 years; 65% male), 46% were being treated with ACE-inhibitors at baseline and 54% were being treated with ARBs. The rate of all-cause mortality and major post-op complications was 22% in both the RASI discontinuation and continuation groups (risk ratio [RR], 1.02; 95% CI, 0.87-1.19; P = 0.85). Episodes of hypotension during surgery were recorded in 41% of patients in the RASI discontinuation group vs. 54% in the RASI continuation group (RR, 1.31; 95% CI, 1.19-1.44). No other differences in trial outcomes were found.

Source:

Legrand M, et al; Stop-or-Not Trial Group. (2024, August 30). JAMA. Continuation vs Discontinuation of Renin-Angiotensin System Inhibitors Before Major Noncardiac Surgery: The Stop-or-Not Randomized Clinical Trial. https://pubmed.ncbi.nlm.nih.gov/39212270/