Prospective Randomized Evaluation of Preoperative Angiotensin‐Converting Enzyme Inhibition (PREOP‐ACEI)

BACKGROUND Intraoperative hypotension is associated with an increased risk of end organ damage and death. The transient preoperative interruption of angiotensin‐converting enzyme inhibitor (ACEI) therapy prior to cardiac and vascular surgeries decreases the occurrence of intraoperative hypotension. OBJECTIVE We sought to compare the effect of two protocols for preoperative ACEI management on the risk of intraoperative hypotension among patients undergoing noncardiac, nonvascular surgeries. DESIGN Prospective, randomized study. SETTING Midwestern urban 489‐bed academic medical center. PATIENTS Patients taking an ACEI for at least six weeks preoperatively were considered for inclusion. INTERVENTIONS Randomization of the final preoperative ACEI dose to omission (n = 137) or continuation (n = 138). MEASUREMENTS The primary outcome was intraoperative hypotension, which was defined as any systolic blood pressure (SBP) < 80 mm Hg. Postoperative hypotensive (SBP < 90 mm Hg) and hypertensive (SBP > 180 mm Hg) episodes were also recorded. Outcomes were compared using Fisher's exact test. RESULTS Intraoperative hypotension occurred less frequently in the omission group (76 of 137 [55%]) than in the continuation group (95 of 138 [69%]) (RR: 0.81, 95% CI: 0.67 to 0.97, P = .03, NNH 7.5). Postoperative hypotensive events were also less frequent in the ACEI omission group (RR: 0.49, 95% CI: 0.28 to 0.86, P = .02) than in the continuation group. However, postoperative hypertensive events were more frequent in the omission group than in the continuation group (RR: 1.95, 95%: CI: 1.14 to 3.34, P = .01). CONCLUSION The transient preoperative interruption of ACEI therapy is associated with a decreased risk of intraoperative hypotension. REGISTRATION ClinicalTrials.gov: NCT01669434.