Continuation versus discontinuation of renin-angiotensin aldosterone system inhibitors before non-cardiac surgery: A systematic review and meta-analysis

A large number of patients undergoing noncardiac surgeries are on long-term use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs). The current guidelines regarding the continuation or discontinuation of renin-angiotensin-aldosterone system inhibitors (RAAS) inhibitors before noncardiac surgery are conflicting. This meta-analysis aims to evaluate whether continuing or withholding RAAS inhibitors before noncardiac surgery influences perioperative mortality and complications. A thorough literature search was performed across PubMed/MEDLINE, Embase, and the Cochrane Library from their inception up to August 30, 2024 to identify eligible randomized controlled trials (RCTs) and cohort studies. Clinical outcomes were evaluated using a random-effects model to pool odds ratios (ORs) with 95 % confidence intervals (CIs). The analysis included 16 studies with a total of 59,105 patients on RAAS inhibitors before noncardiac surgery. Withholding RAAS inhibitors was associated with a significantly lower incidence of intraoperative hypotension (OR = 0.49; 95 % CI = 0.29 to 0.83) and acute kidney injury (AKI) (OR = 0.88; 95 % CI = 0.82 to 0.95) than continuing the therapy. However, there was no statistically significant difference in reducing mortality (OR = 1.10; 95 % CI = 0.86 to 1.40), major adverse cardiovascular events (MACE) (OR = 1.27; 95 % CI = 0.75 to 2.16), myocardial infarction (OR = 0.83; 95 % CI = 0.27 to 2.59) or stroke events (OR = 0.70; 95 % CI = 0.36 to 1.36) between the two groups. Withholding RAAS inhibitors before noncardiac surgery reduces intraoperative hypotension and AKI with nonsignificant effects on mortality and MACE. •Discontinuing RAAS inhibitors before noncardiac surgery reduces intraoperative hypotension and acute kidney injury.•The withholding of RAAS inhibitors does not impact mortality or major adverse cardiovascular events.•Large-scale randomized controlled trials are required to reach a definitive conclusion.