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Should the angiotensin II antagonists be discontinued before surgery?
M Bertrand1, G Godet, K Meersschaert
1Department of Anesthesiology, Pitié-Salpêtrière Hospital, Paris, France.
Insights
Continuing Angiotensin II antagonists (AIIA) before surgery increases hypotension risk during anesthesia induction. Discontinuing AIIA the day before operation is recommended to mitigate these adverse hemodynamic effects in patients undergoing vascular surgery.
Area of Science:
- Anesthesiology
- Cardiovascular Pharmacology
- Hypertension Management
Background:
- Angiotensin II antagonists (AIIA) are used for hypertension treatment.
- Discontinuation of angiotensin-converting enzyme inhibitors before surgery is common due to potential adverse circulatory effects.
- Data on AIIA administration during anesthesia for vascular surgery is lacking.
Purpose of the Study:
- To compare hemodynamic changes during anesthesia induction in patients chronically treated with AIIA.
- To evaluate the impact of AIIA administration on the morning of surgery versus discontinuation.
Main Methods:
- Prospective randomized study with 37 hypertensive patients on AIIA.
- Group I: AIIA discontinued day before surgery (n=18).
- Group II: AIIA administered 1 hour before anesthesia (n=19).
- Hemodynamic variables monitored during anesthesia induction.
- Vasoactive drug use and hypotensive episodes recorded.
Main Results:
- Group II (AIIA given) showed significantly decreased systolic arterial pressure post-induction.
- More frequent and longer-lasting hypotensive episodes occurred in Group II.
- A higher number of patients in Group II experienced hypotension, requiring more vasoactive drugs.
Conclusions:
- Blockade of the renin-angiotensin system with AIIA enhances the hypotensive effect of anesthetic induction.
- Severe hypotension requiring vasoconstrictors is common after general anesthesia induction in patients taking AIIA.
- Discontinuing AIIA the day before surgery may be justified to prevent adverse hemodynamic events.
Unlabelled:
Angiotensin II antagonists (AIIA) are part of a new rational treatment of hypertension. Because adverse circulatory effects during anesthesia can occur in patients chronically treated with angiotensin-converting enzyme inhibitors, some clinicians discontinue them at least 24 h before operation. No data are available concerning AIIA administration in patients scheduled for vascular surgery performed under general anesthesia. The aim of this prospective randomized study was to compare hemodynamics during induction of anesthesia in patients chronically treated with AIIA and those of patients not receiving this drug on the morning before operation. Thirty-seven patients chronically treated with AIIA for hypertension were randomly assigned to two groups: Group I: AIIA discontinued on the day before surgery (n = 18); Group II: AIIA given 1 h before anesthesia (n = 19). Patients received sufentanil 0.4 microg/kg, propofol 1.5 mg/kg, and atracurium 0.5 mg/kg. During the procedure, the anesthesiologist was required to maintain systolic blood pressure and heart rate within 30% of baseline values using intravascular fluid administration and vasoconstric- tors (e.g. , ephedrine, phenylephrine, or terlipressin). Hemodynamic variables were recorded each 1 min. Hemodynamic study ended at incision. The number and duration of hemodynamic events were collected, and total doses of vasoactive drugs were noted in each group. Systolic arterial pressure was significantly decreased in Group II at 5, 15 and 23 min after induction of anesthesia (*P < 0.05). In this group, the decrease in systolic arterial pressure was associated with more frequent episodes of hypotension (AIIA withdrawn: 1 +/- 1; AIIA given: 2 +/- 1; P < 0.01), with a larger number of patients developing at least 1 episode of hypotension (AIIA withdrawn: 12; AIIA given: 19; P < 0.01), and a longer duration of an episode of hypotension (AIIA withdrawn: 3 +/- 4 min; AIIA given: 8 +/- 7 min; P < 0.01), and an increased need for vasoactive drugs. In conclusion, blockade of the renin-angiotensin system increases the potential hypotensive effect of anesthetic induction. A severe hypotensive episode, requiring vasoconstrictor treatment, occurs after induction of general anesthesia in patients chronically treated with AIIA. Recommendations to discontinue AIIA drugs on the day before the surgery may be justified.
Implications:
This prospective randomized study demonstrated that more severe hypotensive episodes, requiring vasoconstrictor treatment, occur after induction of general anesthesia in patients chronically treated with AIIA and receiving this drug on the morning before operation, in comparison with those in whom AIIA were discontinued on the day before operation. Recommendations to discontinue these drugs on the day before the surgery may be justified.