Both strategies yielded similar post-operative outcomes.

A recent clinical trial showed that outcomes were similar whether ACE inhibitors or angiotensin-receptor blockers (ARBs) were held or continued on the day of noncardiac surgery (NEJM JW Gen Med Jun 1 2023 and Ann Intern Med 2023; 176: 605-614). However, that study employed additional strategies in each group to avoid either hypotension or hypertension. Using a simpler study design, French investigators randomised 2222 adults (mean age, 67 years) who were undergoing elective major noncardiac surgery and were using ACE inhibitors or ARBs to either continuation of their medication through the day of surgery or discontinuation at 48 hours prior to surgery. ACE inhibitors and ARBs were resumed as soon as possible after surgery.

The composite primary outcome of all-cause mortality and major post-operative complications was similar (22%) in the two groups, as were individual components of that outcome, including acute kidney injury (11%). Intraoperative vasopressor-requiring hypotension was significantly more common in patients assigned to medication continuation than in those assigned to discontinuation (54% vs 41%; number needed to harm, eight), but duration of hypotension was only three minutes longer (on average) in the continuation group.

Comment: This study further demonstrates that older patients who are under-going major surgery have similar relevant outcomes with either continuation or discontinuation of ACE inhibitors and ARBs preoperatively. In this unblinded study, rapid correction of intraoperative hypotension likely influenced patient outcomes. Nevertheless, for most patients, either continuation or discontinuation seems safe and reasonable, although some guidelines do recommend holding ACE inhibitors and ARBs preoperatively.

Daniel D. Dressler, MD, MSc, MHM, FACP, Professor of Medicine, Emory University School of Medicine, Atlanta, USA.

Legrand M, et al. Continuation vs discontinuation of renin-angiotensin system inhibitors before major noncardiac surgery: the Stop-or-Not randomized clinical trial. JAMA 2024 Aug 30; e-pub (https://doi. org/10.1001/jama.2024.17123).