Perioperative Management of ACE Inhibitors and ARBs

General Recommendations

• The European Society of Cardiology recommends that ACE inhibitors and ARBs should be held 24 hours before non-cardiac surgery in patients taking them for hypertension, but continued perioperatively in patients with left ventricular systolic dysfunction 1, 2
• The American College of Cardiology recommends restarting ACE inhibitors/ARBs as soon as clinically feasible postoperatively when volume status is stable 3, 1

Rationale and Evidence

• The European Society of Cardiology states that perioperative use of ACE inhibitors/ARBs carries a risk of severe hypotension under anesthesia, particularly following induction and with concomitant β-blocker use 1, 2
• The American College of Cardiology guidelines state that continuation of ACE inhibitors or ARBs perioperatively is reasonable (Class IIa recommendation, Level of Evidence B) 3, 4

Special Considerations

• The European Society of Cardiology recommends that if discontinuing ACE inhibitors/ARBs in hypertensive patients, they should be held 24 hours before surgery 1, 2
• The American College of Cardiology recommends ensuring volume status is stable before restarting ACE inhibitors/ARBs postoperatively 3, 1

Algorithm for Decision Making

• For patients with hypertension, the European Society of Cardiology recommends holding ACE inhibitors/ARBs 24 hours before surgery 1, 2
• For patients with left ventricular systolic dysfunction, the European Society of Cardiology recommends continuing ACE inhibitors/ARBs perioperatively with close monitoring 1, 2