Intraoperative cardiac arrest: was it the ACE inhibitor?

Area of Science:

• Anesthesiology
• Cardiovascular Pharmacology

Background:

• Renin-angiotensin-aldosterone system (RAAS) antagonists are commonly prescribed for hypertension and heart failure.
• Their use on the day of surgery is controversial due to potential hemodynamic instability.

Observation:

• A patient undergoing cerebral aneurysm clipping received angiotensin-converting enzyme (ACE) inhibitor therapy on the morning of surgery.
• This resulted in profound postinduction hypotension and cardiac arrest.

Findings:

• The patient was successfully resuscitated and the procedure was repeated 6 weeks later.
• On the second occasion, ACE inhibitor therapy was withheld on the day of surgery, and identical anesthetic management was used without incident.

Implications:

• Withholding RAAS antagonists, specifically ACE inhibitors, on the day of surgery may prevent intraoperative hypotension.
• This case highlights the critical importance of perioperative medication management in patients on RAAS antagonists.