• Pavel S Roshanov, Bram Rochwerg, Ameen Patel, Omid Salehian, Emmanuelle Duceppe, Emilie P Belley-Côté, Gordon H Guyatt, Daniel I Sessler, Yannick Le Manach, Flavia K Borges, Vikas Tandon, Andrew Worster, Alexandra Thompson, Mithin Koshy, Breagh Devereaux, Frederick A Spencer, Robert D Sanders, Erin N Sloan, Erin E Morley, James Paul, Karen E Raymer, Zubin Punthakee, and P J Devereaux.
• From the London Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada (P.S.R.); Departments of Medicine (B.R., A.P., O.S., E.D., E.P.B.-C., G.H.G., F.K.B., V.T., A.W., F.A.S., Z.P., P.J.D.), Clinical Epidemiology and Biostatistics (B.R., E.D., E.P.B.-C., G.H.G., Y.L.M., A.W., P.J.D.), and Anesthesiology (Y.L.M., J.P., K.E.R.), McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada (E.D., E.P.B.-C., Y.L.M., F.K.B., A.T., M.K., B.D., P.J.D.); Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S.); Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin (R.D.S.); and Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (E.N.S., E.E.M.).
• Anesthesiology. 2017 Jan 1; 126 (1): 16-27.

BackgroundThe effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before noncardiac surgery is unknown.MethodsIn this international prospective cohort study, the authors analyzed data from 14,687 patients (including 4,802 angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users) at least 45 yr old who had in-patient noncardiac surgery from 2007 to 2011. Using multivariable regression models, the authors studied the relationship between withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and a primary composite outcome of all-cause death, stroke, or myocardial injury after noncardiac surgery at 30 days, with intraoperative and postoperative clinically important hypotension as secondary outcomes.ResultsCompared to patients who continued their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, the 1,245 (26%) angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users who withheld their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in the 24 h before surgery were less likely to suffer the primary composite outcome of all-cause death, stroke, or myocardial injury (150/1,245 [12.0%] vs. 459/3,557 [12.9%]; adjusted relative risk, 0.82; 95% CI, 0.70 to 0.96; P = 0.01) and intraoperative hypotension (adjusted relative risk, 0.80; 95% CI, 0.72 to 0.93; P < 0.001). The risk of postoperative hypotension was similar between the two groups (adjusted relative risk, 0.92; 95% CI, 0.77 to 1.10; P = 0.36). Results were consistent across the range of preoperative blood pressures. The practice of withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers was only modestly correlated with patient characteristics and the type and timing of surgery.ConclusionsWithholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. A large randomized trial is needed to confirm this finding. In the interim, clinicians should consider recommending that patients withhold angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 24 h before surgery.

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