Continuation Versus Discontinuation of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Patients Undergoing Noncardiac Surgery

There has been ongoing debate about whether to continue or withhold angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in patients undergoing noncardiac surgery. With over 200 million surgeries performed annually worldwide and millions of patients on ACE inhibitors and ARBs, it is crucial to elucidate the best management strategy for patients undergoing noncardiac surgery while on these medications. Several large randomized controlled trials, the Stop-or-Not and the Perioperative Ischemic Evaluation-3 trials, were conducted to investigate this important issue. Both clinical trials demonstrated no difference in cardiovascular adverse events, including vascular death, myocardial injury, stroke, and cardiac arrest, with continuation versus discontinuation of ACE inhibitors or ARBs in patients undergoing noncardiac surgery. However, these clinical trials showed a higher incidence of intraoperative hypotension in patients who continued taking their ACE inhibitor or ARB through the surgery. Based on this evidence, the American College of Cardiology 2024 Perioperative Guidelines recommend that patients undergoing elevated-risk surgery should have their ACE inhibitor or ARB withheld 24 hours before the surgery; however, patients with heart failure with reduced ejection fraction undergoing noncardiac surgery should continue their regimen. Currently, while the evidence indicates no difference in adverse outcomes between continuing and discontinuing ACE inhibitors and ARBs in patients undergoing noncardiac surgery, the decision to continue or withhold these medications remains individualized. Clinicians must consider various patient and clinical factors when making this decision, including the type of surgery, the risk for intraoperative blood loss and hypotension, and the specific indication of the ACE inhibitor or ARB.