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Published on: July 19, 2011
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.
Insights
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.
Background:
It remains unclear whether to continue or withdraw angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEI) before noncardiac surgery to reduce perioperative morbidity. This systematic review and meta-analysis aimed to analyze the consequences of continuing ARB or ACEi in the incidence of intraoperative hypotension and postoperative complications.
Methods:
This systematic review and meta-analysis followed the PRISMA 2020 guidelines and was registered in the PROSPERO database. We conducted a comprehensive search in several bibliographic databases for studies comparing continuing versus withholding renin angiotensin aldosterone system antagonists before noncardiac surgery. Primary outcomes included the incidence of intraoperative hypotension, while secondary outcomes covered the intraoperative use of the vasoactive agent, the incidence of severe hypotension, intraoperative and postoperative hypertension, the incidence of acute kidney injury (AKI), 30-day postoperative all-cause mortality, and the incidence of major cardiocerebral events (MACCE).
Results:
Five randomized controlled trials, three nonrandomized controlled trials, and four retrospective case-control studies were included that involved 50184 patients. Meta-analysis revealed that continuing ACEI or ARBs before surgery increased the incidence of intraoperative hypotension (OR = 1.96, 95%CI [1.30, 2.96] p=0.001). Heterogeneity was substantial across studies but was significantly reduced in subgroup analyses. Furthermore, the use of vasoactive agents and the incidence of severe hypotension were significantly higher in the continuing group. No significant differences in intraoperative hypertension and the incidence of AKI and MACCE at 30 days after the operation.
Conclusions:
Continued ACEI or ARBs before non-cardiac surgery increases the incidence of intraoperative hypotension, without reducing the incidence of both AKI and MACCE postoperatively. More research is necessary to explore the appropriate perioperative management of ACE-I and ARB.
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