Does withholding an ACE inhibitor or ARB before surgery improve outcomes?

Abstract

Q: Does withholding an ACE inhibitor or ARB before surgery improve outcomes? EVIDENCE-BASED ANSWER: A GUARDED YES, because the evidence of benefit is from observational studies and applies to noncardiac surgery. Withholding angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) 24 hours before noncardiac surgery has been associated with a 30-day lower risk for all-cause death, stroke, myocardial injury, and intraoperative hypotension (18% adjusted relative risk reduction). The finding is based on 1 international prospective cohort study and, of note, is an association and a likelihood of benefit. Confirmation would require a large randomized trial (RCT; strength of recommendation [SOR]: B, good-quality international prospective cohort study).