Continuation versus Discontinuation of RASIs Before Major Noncardiac Surgery: Which Is Superior?

Legrand M, Falcone J, Cholley B, et al. Continuation vs Discontinuation of Renin-Angiotensin System Inhibitors Before Major Noncardiac Surgery: The Stop-or-Not Randomized Clinical Trial. JAMA. 2024;332:970-978.

A significant proportion of patients undergoing major noncardiac surgical procedures have a history of hypertension, diabetes, or heart failure and are undergoing treatment with renin-angiotensin system inhibitors (RASI). The best strategy for managing these patients perioperatively (continue or pause medications) is unknown.

This article reported outcomes of a randomized trial (n = 2,022) comparing continued use of RASI to cessation 48 hours prior to surgery with resumption within the first week postoperatively.

The data showed that rates of all-cause mortality and complications were the same (22%) in the two comparison groups. Intraoperative hypotension occurred in a higher proportion of the continued treatment group, but complications related to hypotension were not increased.

The authors concluded that either continuing or pausing RASI drugs in patients undergoing major noncardiac surgical procedures was safe.