Continuation vs Discontinuation of Renin-Angiotensin System Inhibitors Before Major Noncardiac Surgery
Authors: Legrand Matthieu , Falcone Jérémy , Cholley Bernard , Charbonneau Hélène , Delaporte Amélie , Lemoine Adrien , Garot Matthias , Joosten Alexandre , Meistelman Claude , Cheron-Leroy Delphine , Rives Jean-Philippe , Pastene Bruno , Dewitte Antoine , Sigaut Stéphanie , Danguy des Deserts Marc , Truc Cyrille , Boisson Matthieu , Lasocki Sigismond , Cuvillon Philippe , Schiff Ugo , Jaber Samir , Le Guen Morgan , Caillard Anaïs , Bar Stéphane , Pereira de Souza Neto Edmundo , Colas Vincent , Dimache Florin , Girardot Thibaut , Jozefowicz Elsa , Viquesnel Simon , Berthier Francis , Vicaut Eric , Gayat Etienne ,   Stop-or-Not Trial Group, MONZIOLS Simon , DEFAYE Mylene , CAMUS Thibault , ROBIN Jean-Jacques , OUATTARA Alexandre , FETITA Ioana , JOANNES-BOYAU Olivier , BONNARDEL Eline , BOUQUEREL Rémi , STRZELECKI Antoine , FAYON Thibaut , PELLETIER Christophe , LE GAILLARD Benjamin , GIRARDOT Thibaut , AMOUSSOU Géraud , EL BOUYOUSFI Maalik , GANASCIA Bruno , BUTRULLE Calliope , GERGAUD Soizic , HABRIAL Pierre , PESSIOT Solène , SAMSON Emmanuel , WOLFF Caroline , STANKOVA Nevena , AOUATI Farida , KAVAFYAN Juliette , SUPARSCHI Vlad , LONGROIS Dan , LE ROY Julie , ROSSIGNOL Benoit , HUET Olivier , BOISSON Christophe , BONNIN  Pierre Olivier , DHAOUADI  Mohamed , GARDES Ghislaine , PERIN  Mikael , BRUNET Sophie , GRICOURT Yann , FISCHER Marc-Olivier , DEBROCZI Stéphane , RETOURNAY Lucie , STRUB Pierre , VIVIN Patrice , DUPAYS Rachel , KERFORNE Thomas , VIANET  Gabriel , MANZANO Virginie , NOLL Eric , LUDES Pierre-Olivier , CHAMARAUX-TRAN Thien-Nga , CIRENEI Cédric , HAMROUN Djihad , LEBAS Benoit , ANDRIEU Grégoire ANDRIEU , ETIENNE Vincent , CINOTTI Raphaël , SIMON Natacha , FRASCA Denis , BELOEIL Hélène , LE GALL Amandine , TECHEV Petyo , MEURET Ludovic , JOFFRE Jérémie , DUPONT Hervé , CHARBIT Beny , DAVY Arthur , LOBO David , DEVYS Jean-Michel , SORIA Benjamin , CHOLET Clémentine , MOTAMED Cyrus , WYNIECKI Anne , BILLARD Valérie , DEMIRI Migena , MILLET Clement , DEGOUL Samuel , CANEVET Christophe , MOUNIER Céline , DESRUMAUX Flavie , MARTINEZ Julia , TEXIER Claire , VOISIN Benoit , DUBREUIL Guillaume , DE MONTBLANC Jacques , MENGELLE Claire , RUSCIO Laura , FUTIER Emmanuel , FAYON JULIE , BAIETTO Benoit , VIGNAUD Marie , MUNIER  Yoann , PAQUETTE  Bertille , SAPTEFRAT Diana , MACHROUB Zakia , AUBERT Jean-Sébastien , ABI ABDALLAH Georges , POLGE Nicolas , DACHRAOUI Najla , GODIER Anne , ZLOTNIK Diane , NOUGUE Hélène , CLAUSSE Darless , MA Sabrina , SALAMI-ADJAVON Sherifatou , ROSSIGNOL Patrick , BERTHIER Francis , BARTHÉLÉMY Romain , VIANET  gabriel , LOGEART Damien , REINER Peggy , PAUTRAT Karine , HONG Alex , COROIR Marine , MAYEUR Claire , THES Jacques , LAVERDURE Florent , SERI Sofiane , BERCAN Violeta , IONESCU Cristian Radu , GONNET PINTON Caroline , LEONE Marc , LESAVRE Nathalie , CHATELON Jeanne , POIRIER Marion , RIVORY Adrien , ROULLET Stéphanie , COECKELENBERGH Sean , TOUBAL Leila , RAMADAN Joanna , NOUETTE-GAULAIN Karine , RALEC Bruno , THILL Chloé , GIACARDI Christophe , MONTELESCAUT Etienne , ARIES Philippe , TAVERNIER Benoît , BELLET Julie , DELASSUS Romain , TRIBOUILLARD Hélène , VERZILLI Daniel , MILLOT Alice , DE JONG  Audrey , GENIEZ Marie , MARRE Virginie , PENNE Michaëla , POUZERATTE Yvan , RAO Guillaume , COUTROT Maxime , BLET Alice , PLAUD Benoit , BASTO Emmanuel , PONSIN Mathilde , BECQ Marie-Christine , CHAUSSARD Maïté , NTAHE Aristide , DEPRET François , GUILLEMET Lucie , VALENT Arnaud , FLORES Lyse , BUREY Julien , FERAY Sarah , ELMALEH Yoann , DUPEYRAT Sophie , BAURY Thomas , TACONET Clémentine , RIMMELE Thomas , MAZOCKY  Elodie , PARROUFFE Marie Luce , JADAUD Catherine , ABRARD Stanislas , TRONCHE Pierre-Antoine , VIAL Arthur , AKA Emma , BELLOCQ Anne-Sophie , CARABALONA Jean-François , FAYARD Blandine , GUYADER Jean Marie , HURIAUX Letitia , MILLOT Ingrid , LAMBLIN Antoine , DUTOUR Marine , ROUKHOMOVSKY-MORETTI Mathilde , MEURET Pascal , OMRANI Nadir , RAYMOND Barnabé , ROY Clemence   , SIGWALT Florent , MERINDOL Xavier , DESMARD Mathieu , BOURREAU Louis , ALLAIN Pierre-Antoine , DEI SVALDI Charlotte , ALEXANDER Brenton 
Published: August 2024

Importance

Before surgery, the best strategy for managing patients who are taking renin-angiotensin system inhibitors (RASIs) (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) is unknown. The lack of evidence leads to conflicting guidelines.

Objective

To evaluate whether a continuation strategy vs a discontinuation strategy of RASIs before major noncardiac surgery results in decreased complications at 28 days after surgery.

Design, Setting, and Participants

Randomized clinical trial that included patients who were being treated with a RASI for at least 3 months and were scheduled to undergo a major noncardiac surgery between January 2018 and April 2023 at 40 hospitals in France.

Intervention

Patients were randomized to continue use of RASIs (n = 1107) until the day of surgery or to discontinue use of RASIs 48 hours prior to surgery (ie, they would take the last dose 3 days before surgery) (n = 1115).

Main Outcomes and Measures

The primary outcome was a composite of all-cause mortality and major postoperative complications within 28 days after surgery. The key secondary outcomes were episodes of hypotension during surgery, acute kidney injury, postoperative organ failure, and length of stay in the hospital and intensive care unit during the 28 days after surgery.

Results

Of the 2222 patients (mean age, 67 years [SD, 10 years]; 65% were male), 46% were being treated with angiotensin-converting enzyme inhibitors at baseline and 54% were being treated with angiotensin receptor blockers. The rate of all-cause mortality and major postoperative complications was 22% (245 of 1115 patients) in the RASI discontinuation group and 22% (247 of 1107 patients) in the RASI continuation group (risk ratio, 1.02 [95% CI, 0.87-1.19]; P = .85). Episodes of hypotension during surgery occurred in 41% of the patients in the RASI discontinuation group and in 54% of the patients in the RASI continuation group (risk ratio, 1.31 [95% CI, 1.19-1.44]). There were no other differences in the trial outcomes.

Conclusions and Relevance

Among patients who underwent major noncardiac surgery, a continuation strategy of RASIs before surgery was not associated with a higher rate of postoperative complications than a discontinuation strategy.

Trial Registration

ClinicalTrials.gov Identifier: NCT03374449