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Continuing versus Withholding Renin-Angiotensin-Aldosterone System Antagonists Before Noncardiac Surgery: A
Mohamed Aziz Daghmouri1, Faten Haddad2, Emna Kammoun2
1Department of Anesthesiology, Montreuil Intercommunal Hospital Center, France.
La Tunisie Medicale
|March 18, 2026
Summary
Continuing angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEI) before noncardiac surgery increases intraoperative hypotension. This practice does not reduce postoperative acute kidney injury or major cardiocerebral events.
Area of Science:
- Anesthesiology
- Cardiology
- Nephrology
Background:
- Management of renin-angiotensin-aldosterone system antagonists (RAASAs) before noncardiac surgery is debated.
- Uncertainty exists regarding perioperative morbidity associated with continuing or withdrawing ARBs and ACEIs.
Purpose of the Study:
- To systematically review and meta-analyze the impact of continuing ARBs or ACEIs on perioperative outcomes.
- To evaluate the incidence of intraoperative hypotension and postoperative complications.
Main Methods:
- Systematic review and meta-analysis adhering to PRISMA 2020 guidelines.
- Searched multiple databases for studies comparing continuation versus withholding of RAASAs before noncardiac surgery.
- Included RCTs, non-RCTs, and retrospective case-control studies involving 50,184 patients.
Main Results:
- Continuing ACEIs or ARBs significantly increased intraoperative hypotension (OR = 1.96).
- Higher rates of vasoactive agent use and severe hypotension were observed in the continuation group.
- No significant differences were found in intraoperative hypertension, AKI, or 30-day MACCE.
Conclusions:
- Continuing ACEIs or ARBs before noncardiac surgery elevates the risk of intraoperative hypotension.
- This strategy does not improve postoperative AKI or MACCE rates.
- Further research is needed for optimal perioperative RAASA management.
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