Clinical question: Should renin-angiotensin system inhibitors (RASI) be continued or discontinued before major noncardiac surgery?
Background: Continuation of RASI perioperatively can predispose to intraoperative vasoplegia, but discontinuation may also lead to complications. There is a lack of robust evidence to support either continuation or discontinuation of RASI therapy prior to major noncardiac surgery.
Study design: Multicenter, randomized, clinical trial
Setting: 40 hospitals in France
Synopsis: 2,222 patients planning to undergo major noncardiac surgery were randomized to either a RASI discontinuation strategy (stopping RASI 48 hours before surgery) or a RASI continuation strategy. The primary outcome studied was a composite of death and major postoperative complications such as acute myocardial infarction, acute pulmonary edema, stroke, intensive care unit admission, and acute kidney injury. There was no significant difference between strategy groups, with the composite primary outcome occurring in 22.3% of the continuation group and 22.0% in the discontinuation group (RR, 1.02; 95% CI, 0.87 to 1.19; P=0.85).
The secondary outcome of intraoperative hypotension occurred in 54% of the continuation group compared to 41% in the discontinuation group (RR, 1.31; 95% CI, 1.19 to 1.44). The median duration of intraoperative hypotension was nine minutes in the continuation group and six minutes in the discontinuation group, with a mean difference in duration of hypotension of 3.7 minutes (95% CI, 1.4 to 6.0 minutes).
Bottom line: Discontinuation of RASI before major noncardiac surgery does not significantly reduce major postoperative complications but may reduce the risk of intraoperative hypotension.
Citation: Legrand M, et al. Continuation vs discontinuation of renin-angiotensin system inhibitors before major noncardiac surgery: the Stop-or-not randomized clinical trial. JAMA. 2024;332(12):970-978. doi:10.1001/jama.2024.17123.
Dr. Alex Truong is a hospitalist at UC San Diego Health at the University of California in San Diego