Should lisinopril (angiotensin-converting enzyme inhibitor) be held before surgery to prevent hypotension?

From the Guidelines

Lisinopril should generally be continued up to and including the day of surgery. For most patients, the benefits of maintaining blood pressure control and cardiovascular stability outweigh the theoretical risk of intraoperative hypotension, as suggested by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. However, individual assessment is important, and for major surgeries with anticipated significant blood loss or fluid shifts, some clinicians may consider holding the morning dose on the day of surgery or reducing the dose, based on the patient's baseline blood pressure and overall cardiovascular status.

This approach balances the risks of uncontrolled hypertension against potential intraoperative hypotension. The concern with abruptly stopping ACE inhibitors like lisinopril is that it may lead to rebound hypertension and increased cardiovascular risk. If hypotension does occur during surgery, it can typically be managed with fluids and vasopressors. The decision should ultimately be made in consultation with the anesthesiologist and surgeon, considering the specific surgical procedure, the patient's comorbidities, and their baseline blood pressure control. According to the guideline, continuation of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers perioperatively is reasonable, with a Level of Evidence: B 1.

Some key points to consider include:

• The benefits of maintaining blood pressure control and cardiovascular stability outweigh the theoretical risk of intraoperative hypotension for most patients.
• Individual assessment is crucial, taking into account the patient's baseline blood pressure, overall cardiovascular status, and the specific surgical procedure.
• For major surgeries with anticipated significant blood loss or fluid shifts, holding the morning dose or reducing the dose may be considered.
• Abruptly stopping ACE inhibitors like lisinopril may lead to rebound hypertension and increased cardiovascular risk.
• Hypotension during surgery can typically be managed with fluids and vasopressors.
• The decision should be made in consultation with the anesthesiologist and surgeon, considering the patient's comorbidities and baseline blood pressure control, as supported by the 2014 ACC/AHA guideline 1.

From the FDA Drug Label

Surgery/Anesthesia In patients undergoing major surgery or during anesthesia with agents that produce hypotension, lisinopril may block angiotensin II formation secondary to compensatory renin release If hypotension occurs and is considered to be due to this mechanism, it can be corrected by volume expansion.

• Hypotension risk: Lisinopril can cause symptomatic hypotension, especially in patients with certain conditions such as heart failure, ischemic heart disease, or severe volume depletion.
• Management during surgery: The drug label suggests that lisinopril may block angiotensin II formation during surgery, leading to hypotension, which can be corrected by volume expansion. Lisinopril should not necessarily be held before surgery, but patients should be closely monitored for hypotension, and volume expansion should be used to correct it if it occurs 2.

From the Research

Lisinopril and Surgery

• Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension and congestive heart failure 3, 4.
• The use of ACE inhibitors like lisinopril before surgery has been a topic of discussion due to the potential risk of hypotension during anesthesia 5, 6.

Risk of Hypotension

• A study published in 2001 found that patients who received angiotensin II antagonists (similar to ACE inhibitors) on the morning of surgery had a higher incidence of hypotension during anesthesia compared to those who discontinued the medication the day before surgery 5.
• Another study published in 2010 found that patients who continued to take the ACE inhibitor ramipril until the morning of surgery had a higher risk of hypotension during coronary artery bypass graft surgery compared to those who discontinued the medication 24 hours before surgery 6.

Management of Hypotension

• The use of prophylactic vasopressin infusion has been shown to prevent postoperative hypotension in patients who continue to take ACE inhibitors until the morning of surgery 6.
• Regional anesthesia may also reduce the need for perioperative vasopressors and decrease the risk of hypotension during surgery 7.

Recommendations

• Based on the available evidence, it may be recommended to discontinue lisinopril 24 hours before surgery to reduce the risk of hypotension during anesthesia 5, 6.
• However, the decision to discontinue lisinopril should be made on a case-by-case basis, taking into account the individual patient's medical history and the type of surgery being performed.