Renin-angiotensin-aldosterone system (RAAS) antagonists in the perioperative setting: An updated review

Renin-angiotensin-aldosterone system (RAAS) antagonists are essential in managing heart failure, hypertension, chronic kidney disease, and atherosclerotic cardiovascular disease. However, their perioperative use remains controversial due to concerns about intraoperative hypotension and vasoplegia. This review offers an updated synthesis of guideline recommendations, mechanistic insights, and clinical trial evidence, including POISE-3, STOP-OR-NOT, and SPACE, along with a practical decision-making framework for internists. We examine the physiological basis for holding or continuing RAAS antagonists amidst anesthetic interactions, fluid shifts, and cardiovascular risks. Evidence indicates that continuing RAAS antagonists until the day of surgery may raise the risk of intraoperative hypotension but does not consistently worsen major postoperative outcomes. Discontinuation might be suitable for patients with low cardiovascular risk or those undergoing high-risk procedures. We also discuss when and how to resume therapy, incorporate biomarkers like NT-proBNP for risk stratification, and explore emerging approaches such as ARNIs and pharmacogenomics. This review advocates for an individualized, evidence-based approach to RAAS management across surgical contexts.