Perioperative Management of ACE Inhibitors and ARBs
ACE inhibitors and ARBs should be held 24 hours before non-cardiac surgery in patients taking them for hypertension, but continued perioperatively in patients with left ventricular systolic dysfunction. 1
General Recommendations
For Hypertension Patients:
- Transient discontinuation of ACE inhibitors/ARBs should be considered 24 hours before non-cardiac surgery when they are prescribed for hypertension 1
- Withholding ACE inhibitors/ARBs on the day before surgery may reduce the risk of intraoperative hypotension 2
- Restart ACE inhibitors/ARBs as soon as clinically feasible postoperatively when volume status is stable 1
For Heart Failure Patients:
- Continue ACE inhibitors/ARBs during non-cardiac surgery in stable patients with left ventricular systolic dysfunction 1
- ACE inhibitors are specifically recommended for cardiac-stable patients with LV systolic dysfunction scheduled for high-risk surgery 1
- For patients with LV systolic dysfunction scheduled for low/intermediate-risk surgery, ACE inhibitors should be considered 1
Rationale and Evidence
Risk of Intraoperative Hypotension
- Perioperative use of ACE inhibitors/ARBs carries a risk of severe hypotension under anesthesia, particularly following induction and with concomitant β-blocker use 1
- Meta-analyses show that patients continuing ACE inhibitors/ARBs are 41% more likely to develop hypotension during anesthesia compared to those who discontinue these medications (RR = 1.41,95% CI: 1.21-1.64) 3
- The risk of hypotension is at least as high with ARBs as with ACE inhibitors, and the response to vasopressors may be impaired 1
Cardiovascular Benefits
- Despite the increased risk of intraoperative hypotension, continuing ACE inhibitors/ARBs has not been associated with differences in major adverse cardiovascular events, myocardial injury, stroke, acute kidney injury, or death 3
- The 2014 ACC/AHA guidelines state that continuation of ACE inhibitors or ARBs perioperatively is reasonable (Class IIa recommendation, Level of Evidence B) 1
- For patients with LV systolic dysfunction, the benefits of continuing ACE inhibitors/ARBs likely outweigh the risks 1
Special Considerations
Timing of Discontinuation
- If discontinuing ACE inhibitors/ARBs in hypertensive patients, they should be held 24 hours before surgery 1
- Studies show that patients who received ACE inhibitors/ARBs on the morning of surgery required vasopressors significantly more often and in higher dosages 4
Postoperative Restart
- ACE inhibitors/ARBs should be restarted as soon as clinically feasible postoperatively 1
- Ensure volume status is stable before restarting these medications 1
Monitoring
- When continuing ACE inhibitors/ARBs perioperatively in patients with LV systolic dysfunction, close hemodynamic monitoring is recommended 1
- Be prepared to manage potential hypotension with appropriate fluid administration and vasopressors 3, 2
Common Pitfalls and Caveats
- Abrupt discontinuation of ACE inhibitors/ARBs may lead to rebound hypertension in some patients, particularly those with poorly controlled hypertension 5
- Ensure clear communication about which medications to take or withhold on the morning of surgery to avoid confusion 5
- The decision to continue or withhold ACE inhibitors/ARBs should consider the indication for the medication, with different approaches for hypertension versus heart failure 1
Algorithm for Decision Making
- Identify primary indication for ACE inhibitor/ARB therapy:
- Consider surgical risk:
- Plan for postoperative management:
- Restart ACE inhibitors/ARBs as soon as volume status is stable 1