Angiotensin-converting enzyme inhibitors in cardiovascular anesthesia

Besides the long-term regulation of extracellular fluid volume, the RAS plays an important physiologic role in maintaining venous return and blood pressure during acute hemodynamic stresses. ACE inhibitors may therefore alter venous return and cardiac output regulation during anesthesia and surgery. This may be regarded as a drawback of ACE inhibition when other factors interfere with cardiovascular homeostasis; deleterious hemodynamic events may therefore occur when blood volume is decreased, which may be frequent during cardiovascular anesthesia and surgery. However, the alternative solution should not be to stop ACE inhibitors preoperatively. This would allow recovery of RAS control of blood pressure, but at the expense of some regional circulations. From this point of view, preliminary results from early studies during cardiovascular anesthesia and surgery showing redistribution of regional blood flow with inhibition of ACE are encouraging; whether postoperative outcome can be improved deserves further studies. At this time, the evidence is that ACE inhibition does not allow the anesthesiologist to be tolerant of hypovolemia.