What is the current recommendation for continuing or discontinuing Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs) before non-cardiac surgery?

Perioperative Management of ACEIs/ARBs in Non-Cardiac Surgery

Continuation of ACE inhibitors or ARBs is reasonable perioperatively for most patients undergoing non-cardiac surgery. 1

General Recommendations

• For most patients on chronic ACE inhibitors or ARBs, perioperative continuation is reasonable (Class IIa, Level of Evidence B) 1
• If ACE inhibitors or ARBs are held before surgery, it is reasonable to restart them as soon as clinically feasible postoperatively (Class IIa, Level of Evidence C) 1
• In select patients with controlled blood pressure undergoing elevated-risk non-cardiac surgery, omission of renin-angiotensin-aldosterone system inhibitors (RAASi) 24 hours before surgery may be beneficial to limit intraoperative hypotension (Class IIb, Level of Evidence B-R) 1
• In patients on chronic RAASi for heart failure with reduced ejection fraction (HFrEF), perioperative continuation is reasonable 1

Evidence Analysis

Continuation vs. Withholding

• Meta-analyses of studies including 6,022 patients have shown that while intraoperative hypotension was more common in patients who continued ACEIs/ARBs, there was no difference in major adverse cardiovascular events (MACE) 1, 2
• The 2014 ACC/AHA guidelines recommend continuation of ACEIs/ARBs perioperatively with a Class IIa recommendation (reasonable to do) 1
• The 2024 ACC/AHA guidelines provide more nuanced recommendations, suggesting that in select patients with controlled blood pressure undergoing elevated-risk procedures, omitting RAASi 24 hours before surgery may be beneficial to limit intraoperative hypotension 1

Special Considerations

• For patients on chronic RAASi for heart failure with reduced ejection fraction (HFrEF), perioperative continuation is reasonable 1
• Recent evidence from POISE-3 demonstrated no difference in major vascular events in patients randomized to continue or withhold antihypertensive medications, including ACEIs/ARBs 1
• If ACEIs/ARBs are withheld, they should be restarted as soon as clinically feasible postoperatively 1

Clinical Decision Algorithm

1. Assess indication for ACEIs/ARBs:

   • Heart failure with reduced ejection fraction → Continue perioperatively 1
   • Hypertension only → Consider risk factors below 1

2. Evaluate surgical risk:

   • Low-risk procedure → Continue ACEIs/ARBs 1
   • Elevated-risk procedure → Consider withholding 24 hours before surgery if blood pressure is well-controlled 1

3. Consider hemodynamic stability:

   • History of intraoperative hypotension → Consider withholding 1, 2
   • Stable hemodynamics → Continue ACEIs/ARBs 1

Common Pitfalls and Caveats

• Rebound hypertension: Abrupt discontinuation of ACEIs/ARBs may lead to rebound hypertension in some patients, particularly those with poorly controlled hypertension 1, 3
• Intraoperative hypotension: Continuing ACEIs/ARBs may increase the risk of intraoperative hypotension, which may require more vasopressor support 1, 2
• Medication adherence: Ensure clear communication about which medications to take or withhold on the morning of surgery to avoid confusion 1
• Postoperative restart: If ACEIs/ARBs are held, they should be restarted as soon as clinically feasible postoperatively to maintain long-term cardiovascular benefits 1

The decision to continue or withhold ACEIs/ARBs should be made after considering the patient's indication for these medications, the type of surgery, and the risk of intraoperative hypotension versus the risk of adverse cardiovascular events from withholding these medications.