Discontinuation of renin-angiotensin system inhibitors before non-cardiac surgery: a meta-analysis.
Joseph Y Bena Nnang, Ticha B T Tembi, Samuel G J Fodop et al.
✦ AI-curated · Sources linked
In 30 seconds
This systematic review and meta-analysis of five randomized controlled trials compared discontinuation with continuation of renin-angiotensin system inhibitors before non-cardiac, non-vascular surgery. Among 10 773 patients, discontinuation probably reduced peri-operative hypotension: 27.66% vs 34.06% (risk ratio 0.81, 95% confidence interval 0.73-0.89; moderate-certainty evidence). Evidence was very uncertain for peri-operative hypertension, while estimates for acute kidney injury, acute heart failure, myocardial infarction, stroke, and arrhythmias suggested little to no difference, with low-certainty evidence.
Key findings
- Peri-operative hypotension occurred in 27.66% with discontinuation vs 34.06% with continuation (RR 0.81, 95% CI 0.73-0.89; moderate certainty).
- Evidence for peri-operative hypertension was very uncertain: 9.46% vs 8.05% (RR 1.38, 95% CI 0.66-2.89).
- Discontinuation suggested little to no difference in acute kidney injury (10.45% vs 10.69%; RR 0.98, 95% CI 0.66-1.45; low certainty).
- Low-certainty evidence suggested little to no difference in acute heart failure, myocardial infarction, stroke, or arrhythmias.
Why it matters
Peri-operative RAS inhibitor management involves balancing hypotension against possible hypertension and cardiovascular complications. This synthesis indicates that withholding treatment probably reduces hypotension, but does not establish a clear effect on hypertension or major clinical outcomes. The differing certainty of evidence is important when interpreting the apparent benefit and weighing it against unresolved risks.
What to keep in mind
Only five randomized trials were included. Evidence for major clinical outcomes was low certainty, and evidence for peri-operative hypertension was very low certainty.