Indications for ACE Inhibitor Continuation Before Surgery

Angiotensin-converting enzyme (ACE) inhibitors are widely prescribed for hypertension, heart failure with reduced ejection fraction (HFrEF), ischemic heart disease, and chronic kidney disease. Their perioperative management remains controversial because of competing concerns regarding cardiovascular protection and the risk of intraoperative hypotension. A review of the medical literature highlights situations in which continuation of ACE inhibitors before surgery may be appropriate and clinically justified.

ACE inhibitors exert beneficial cardiovascular and renal effects beyond blood pressure control, including reduced ventricular remodeling, improved endothelial function, and attenuation of neurohormonal activation. In patients with HFrEF, these effects are central to morbidity and mortality reduction. Abrupt withdrawal of ACE inhibitors in such patients may lead to hemodynamic deterioration, worsening heart failure, or rebound hypertension, negatively impacting both long-term health and perioperative management. Observational studies in both cardiac and noncardiac surgery populations suggest that continuation of chronic ACE inhibitor therapy is associated with lower postoperative mortality and reduced rates of major adverse cardiovascular events, particularly in patients with established cardiovascular disease.

One of the main concerns with ACE inhibitor continuation before surgery is the increased incidence of intraoperative hypotension, especially during induction of anesthesia. ACE inhibitors impair the renin–angiotensin–aldosterone system’s ability to compensate for anesthesia-induced vasodilation, which can result in hypotension that is sometimes resistant to standard vasopressors. Numerous studies demonstrate a higher frequency of hypotensive episodes when ACE inhibitors are taken on the day of surgery. However, most randomized trials and meta-analyses have not shown a corresponding increase in core clinical outcomes such as myocardial infarction, stroke, acute kidney injury, or death. This suggests that while hypotension is more common, it may be manageable in appropriately selected patients.

Current guideline recommendations support an individualized approach. Continuation of ACE inhibitors before surgery is generally considered reasonable in patients with compelling indications, particularly those with HFrEF or significant left ventricular dysfunction, where the benefits of ongoing neurohormonal blockade likely outweigh the risks. Continuation may also be appropriate in patients with poorly controlled hypertension or high cardiovascular risk, provided close intraoperative hemodynamic monitoring is available.

In contrast, patients taking ACE inhibitors solely for uncomplicated hypertension may derive less perioperative benefit from continuation. In these individuals, temporary withholding of ACE inhibitors 24 hours before surgery is often favored to reduce the risk of intraoperative hypotension, with prompt resumption postoperatively once the patient is euvolemic and hemodynamically stable. Importantly, early postoperative reinstitution of ACE inhibitors has been associated with improved outcomes and should not be delayed unnecessarily.

In summary, the literature supports continuation of ACE inhibitors before surgery in patients with strong cardiovascular indications, particularly heart failure and significant cardiac disease, while selective withholding may be appropriate for lower-risk patients treated only for hypertension. The decision should be individualized, incorporating patient comorbidities, surgical risk, and anesthetic considerations, with close collaboration between surgical, anesthesia, and medical teams.

References

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2. Roshanov PS, Rochwerg B, Patel A, et al. Withholding versus continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers before noncardiac surgery. Anesthesiology. 2017;126(1):16-27. DOI: 10.1097/ALN.0000000000001404

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4. Howell SJ. Systolic hypertension and ACE inhibitor therapy in the perioperative period. Cleveland Clinic J Med.2009;76(suppl 4):S79-S83. DOI: https://doi.org/10.36011/cpp.2021.3.e7

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