Effect of discontinuing antihypertensives on perioperative hypotension in older patients before non-cardiac surgery: multicentre, randomised, double blind, controlled trial.

In 30 seconds

This multicentre, randomised, double blind, placebo controlled trial assessed whether withholding ACE inhibitors or ARBs on the morning of surgery reduces perioperative hypotension in older adults undergoing non-cardiac surgery under general anaesthesia. Among 2012 patients who completed the study, hypotension occurred in 31.2% of those who received placebo rather than their usual medication, compared with 45.5% of those who continued treatment (adjusted odds ratio 0.52, 95% CI 0.43 to 0.63). Withholding treatment also reduced vasopressor use; 30 day complications and mortality did not differ significantly.

Key findings

• Perioperative hypotension occurred in 31.2% with medication withheld versus 45.5% with medication continued; adjusted odds ratio 0.52 (95% CI 0.43 to 0.63).
• Vasopressor use was 28.5% with medication withheld versus 41.1% with continuation; adjusted odds ratio 0.54 (95% CI 0.44 to 0.66).
• Hypotension duration was shorter when medication was withheld: adjusted mean difference -1.3 minutes (95% CI -1.8 to -0.8 minutes).
• Intraoperative fluid volume, postoperative hypotension, 30 day complications, and mortality did not differ significantly between groups.

Why it matters

Perioperative hypotension and vasopressor use were less frequent when older patients omitted their ACE inhibitor or ARB on the morning of surgery. The absence of a significant difference in 30 day complications or mortality provides relevant short-term safety context, although the trial does not establish effects beyond the outcomes and follow-up reported.

What to keep in mind

The study enrolled patients aged 60-80 years undergoing non-cardiac surgery under general anaesthesia at five tertiary teaching hospitals in China; applicability beyond this population and setting is uncertain.