Dr. Murat Demirci

Continuation vs Discontinuation of Renin-Angiotensin System Inhibitors Before Major Noncardiac Surgery (The Stop-or-Not Randomized Clinical Trial)

Published in Congress: ESC 2024

Link :
https://jamanetwork.com/journals/jama/fullarticle/2823118#:~:text=There%20were%20no%20other%20differences,complications%20than%20a%20discontinuation%20strategy.
Backround:
Renin-angiotensin system inhibitors (RASI) are widely used in the treatment of conditions such as myocardial infarction, heart failure, hypertension, and diabetes. However, there is no clear evidence on how these medications should be managed before major non-cardiac surgery. Continuing RASI therapy during surgery may lead to intraoperative hypotension, while discontinuing the therapy may increase the risk of postoperative complications. This study evaluates the effects of preoperative strategies of continuing versus discontinuing RASI therapy on postoperative complications.

Objective:
The purpose of this study is to assess whether continuing or discontinuing RASI therapy prior to major non-cardiac surgery results in fewer postoperative complications in patients undergoing these procedures.

Methods:
The study included patients who had used an Angiotensin-Converting Enzyme Inhibitor or Angiotensin receptor blocker within the last 3 months before surgery and underwent major non-cardiac surgery. Participants were randomized in a 1:1 ratio into either the continuation or discontinuation groups of RASI therapy. Patients undergoing emergency surgeries, those with terminal illness, glomerular filtration rate (GFR) below 15, or preoperative shock were excluded from the study. The continuation group continued taking RASI therapy up until the day of surgery, while in the discontinuation group, the medication was stopped 48 hours prior to surgery. The primary endpoints were defined as all-cause mortality and major postoperative complications.

Results:
In the study, 2,222 patients were randomly divided into two groups: the group that continued RASI therapy (1,107 patients) and the group that discontinued RASI therapy (1,115 patients). The rates of all-cause mortality and major postoperative complications within 28 days were found to be 22% in both groups. However, intraoperative hypotension was observed in 54% of patients in the group that continued RASI therapy, compared to 41% in the group that discontinued therapy. No significant differences were found between the groups regarding other secondary outcomes.

Conclusion:
Discontinuing RASI medications before major non-cardiac surgery did not increase the risk of postoperative complications.

Interpretations:
This study demonstrates that continuing or discontinuing RASI therapy before major non-cardiac surgery results in similar outcomes regarding postoperative complications. However, continuing RASI therapy may increase the risk of intraoperative hypotension. This finding provides important guidance for surgeons and clinicians in managing RASI therapy. In particular, discontinuation of RASI therapy might be considered in situations where the risk of intraoperative hypotension is high.