Evaluating the risks and benefits of continuing versus withholding renin–angiotensin system inhibitors: a systematic review and meta-analysis with trial sequential analysis

Shalabi L., Ibrahim A., Zreigh S., Rifai M., Ramadan S., Arafa M. A., ...More

BJA Open, vol.14, 2025 (Scopus) identifier

  • Publication Type: Article / Review
  • Volume: 14
  • Publication Date: 2025
  • Doi Number: 10.1016/j.bjao.2025.100405
  • Journal Name: BJA Open
  • Journal Indexes: Scopus
  • Keywords: ACE-inhibitors, angiotensin receptor blockers, cardiovascular complications, intraoperative hypotension, mortality, noncardiac surgery, RASi
  • Ankara Yıldırım Beyazıt University Affiliated: Yes

Abstract

Background: The best perioperative management of renin–angiotensin system inhibitors (RASi) in patients undergoing noncardiac surgery has been an ongoing debate as a result of inconclusive previous studies and insufficient data for robust guidelines. Although continuation of RASi may lead to intraoperative hypotension, withholding might also cause postoperative complications. Our meta-analysis aims to explore the postoperative outcomes of strategies of RASi management before surgery by evaluating randomised clinical trials, to provide more definitive conclusions for clinical practice. Methods: We systematically searched PubMed, Scopus, Cochrane, and Web of Science until September 2024. Inclusion criteria included patients (≥18 yr) who underwent noncardiac surgery and received long-term RASi, which were either withheld or continued before surgery. Statistical analysis was conducted using R Studio version 4.4.2. Results: A total of seven RCTs with 8741 patients receiving long-term RASi before noncardiac surgery revealed no significant difference between continuation and withholding groups regarding cardiovascular complications (risk ratio [RR] 0.94, 95% confidence interval [CI] 0.80–1.09, P=0.41), mortality (RR 1.16, 95% CI 0.55–2.43, P=0.71), and acute kidney injury (RR 0.95, 95% CI 0.84–1.06, P=0.33). However, continuation of RASi was associated with a higher incidence of intraoperative hypotension (RR 1.33, 95% CI 1.23–1.44, P<0.001). Additionally, the incidence of postoperative severe hypertension (systolic BP >180 mm Hg) was significantly lower in the continuation group (RR 0.63, 95% CI 0.40–0.98, P<0.002). Conclusions: Continuing RASi before noncardiac surgery does not significantly impact mortality, cardiovascular complications or the risk of acute kidney injury. However, continuation is associated with an increased risk of intraoperative hypotension, and withholding with a higher risk of postoperative severe hypertension. Systematic review protocol: CRD42024605208 (PROSPERO).