Perioperative Management of ACEIs/ARBs in Non-Cardiac Surgery

General Recommendations

The American College of Cardiology recommends continuation of ACE inhibitors or ARBs perioperatively for most patients undergoing non-cardiac surgery, with a Class IIa recommendation (reasonable to do) 1, 2, 3
For patients on chronic ACE inhibitors or ARBs, perioperative continuation is reasonable, with a Class IIa recommendation and Level of Evidence B 3, 4
If ACE inhibitors or ARBs are held before surgery, it is reasonable to restart them as soon as clinically feasible postoperatively, with a Class IIa recommendation and Level of Evidence C 3, 4
In select patients with controlled blood pressure undergoing elevated-risk non-cardiac surgery, omission of renin-angiotensin-aldosterone system inhibitors (RAASi) 24 hours before surgery may be beneficial to limit intraoperative hypotension, with a Class IIb recommendation and Level of Evidence B-R 5, 6

Meta-analyses of studies including 6,022 patients have shown that while intraoperative hypotension was more common in patients who continued ACEIs/ARBs, there was no difference in major adverse cardiovascular events (MACE) 5
The 2014 ACC/AHA guidelines recommend continuation of ACEIs/ARBs perioperatively with a Class IIa recommendation (reasonable to do) 3, 7
Recent evidence from POISE-3 demonstrated no difference in major vascular events in patients randomized to continue or withhold antihypertensive medications, including ACEIs/ARBs 5, 6

For patients on chronic RAASi for heart failure with reduced ejection fraction (HFrEF), perioperative continuation is reasonable 5
If ACEIs/ARBs are withheld, they should be restarted as soon as clinically feasible postoperatively to maintain long-term cardiovascular benefits 3, 4

The American College of Cardiology recommends assessing indication for ACEIs/ARBs and evaluating surgical risk to determine whether to continue or withhold these medications perioperatively 2, 5, 6

Abrupt discontinuation of ACEIs/ARBs may lead to rebound hypertension in some patients, particularly those with poorly controlled hypertension 8
Continuing ACEIs/ARBs may increase the risk of intraoperative hypotension, which may require more vasopressor support 5
Ensure clear communication about which medications to take or withhold on the morning of surgery to avoid confusion 7, 9
If ACEIs/ARBs are held, they should be restarted as soon as clinically feasible postoperatively to maintain long-term cardiovascular benefits 3, 4