Withholding vs. continuing angiotensin-converting enzyme inhibitors or angiotensin receptor blockers before surgery: a systematic review and meta-analysis of randomized controlled trials

The optimal preoperative management of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) remains debated. This meta-analysis of randomized controlled trials (RCTs) assessed withholding vs. continuing ACEIs/ARBs on intraoperative hypotension and postoperative outcomes. PubMed, Web of Science, and China Biology Medicine were comprehensively searched to identify RCTs comparing preoperative withholding ACEIs/ARBs with a continuing therapy in adult patients. Two authors independently extracted and pooled data using a random-effects model. The primary outcome was the incidence of intraoperative hypotension. Secondary outcomes included duration of intraoperative hypotension, vasopressor use, postoperative hypotension and hypertension, major adverse cardiovascular events, acute kidney injury, duration of mechanical ventilation, length of stay in ICU and hospital, and 30-d mortality. Evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach. Fourteen RCTs with 4063 patients were included. Withholding ACEIs/ARBs before noncardiac surgery was associated with a reduced incidence of intraoperative hypotension (36.4% vs. 48.4%; risk ratio = 0.73, 95% confidence interval = 0.60–0.88, <i>p</i> = 0.001, <i>I²</i> = 63%; a very low certainty of evidence); it was associated with a shorter duration of intraoperative hypotension (mean difference = −5.41 min), reduced vasopressor use (37.5% vs. 51.2%), and increased postoperative hypertension (27.8% vs. 20.2%), without affecting other outcomes (low or very low certainty of evidence). While withholding ACEIs/ARBs may reduce intraoperative hypotension, the very low certainty of evidence underscores the need for future research to confirm clinical implications. PROSPERO (CRD42021253965).