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Continuation versus Discontinuation of Renin-Angiotensin System Inhibitors Before Noncardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Muhammad Saad,M. U. Sohail,Ifrah Ansari,Haiqa Aamer,Aymen Ahmed,Muhammad Sameer Arshad,Anmol Mohan,Vikash Kumar,C. Alraies

Published 2025 in Journal of Cardiothoracic and Vascular Anesthesia

ABSTRACT

OBJECTIVES The optimal management of renin-angiotensin system inhibitors (RASIs) before noncardiac surgery remains unclear. Continuing RASIs may increase intraoperative hypotension, while discontinuation risks postoperative hypertension and heart failure. Current guidelines suggest withholding RASI 24 hours prior to surgery, but evidence is limited. This meta-analysis of randomized controlled trials aimed to clarify the risks and benefits of continuing versus withholding RASIs in this setting. DESIGN A systematic review of randomized clinical trials (RCTs) and meta-analysis. SETTING A comprehensive electronic search conducted in PubMed, Scopus, and Cochrane from inception to August 2024. PARTICIPANTS Nine clinical trials that collectively enrolled 8,906 patients undergoing noncardiac surgery. INTERVENTIONS A comparison of continuation versus discontinuation of RASIs preoperatively in patients undergoing noncardiac surgery. MEASUREMENTS AND MAIN RESULTS The primary outcomes were intraoperative hypotension, major adverse cardiovascular events (MACE), and all-cause mortality. Secondary outcomes included acute kidney injury (AKI) and postoperative hypertension. Patients who discontinued RASIs had a significantly lower incidence of intraoperative hypotension (risk ratio [RR], 0.66; 95% confidence interval [CI], 0.52-0.84) compared to those who continued treatment. No significant differences were observed in all-cause mortality (RR, 0.85; 95% CI, 0.40-1.85), MACE (RR, 1.01; 95% CI, 0.87-1.17), AKI (RR, 0.98; 95% CI, 0.79-1.22), and postoperative hypertension (RR, 1.57; 95% CI, 0.92-2.68). CONCLUSIONS Continuation of RASIs significantly increased the risk of intraoperative hypotension compared to discontinuation of treatment. Overall, no significant differences were observed in all-cause mortality, MACE, AKI, or postoperative hypertension between patients who continued or discontinued RASIs preoperatively.

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