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, p = 0.001, I2 = 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).血管紧张素转换酶抑制剂（angiotensin-converting enzyme inhibitors, ACEIs）与血管紧张素Ⅱ受体拮抗剂（angiotensin receptor blockers, ARBs）的最优术前管理方案仍存在争议。本项针对随机对照试验（randomized controlled trials, RCTs）的荟萃分析，旨在评估术前暂停与持续使用ACEIs/ARBs对术中低血压及术后结局的影响。研究全面检索了PubMed、Web of Science及中国生物医学文献数据库，筛选纳入成人患者术前暂停ACEIs/ARBs与持续给药方案对比的随机对照试验。由两名研究者独立提取数据并采用随机效应模型进行合并分析。本研究的主要结局指标为术中低血压的发生率；次要结局指标包括术中低血压持续时长、血管活性药物使用情况、术后低血压与高血压发生率、主要不良心血管事件、急性肾损伤、机械通气时长、重症监护病房（ICU）及医院住院时长，以及30天死亡率。研究证据质量采用推荐分级、评估、制定与评价（Grading of Recommendations, Assessment, Development and Evaluation, GRADE）方法进行评估。本研究共纳入14项随机对照试验，涉及4063例患者。非心脏手术术前暂停ACEIs/ARBs可降低术中低血压发生率（36.4% vs. 48.4%；风险比=0.73，95%置信区间=0.60~0.88，P=0.001，I²=63%；证据质量极低）；同时可缩短术中低血压持续时长（均数差=-5.41 min）、减少血管活性药物使用（37.5% vs. 51.2%），但会增加术后高血压发生率（27.8% vs. 20.2%），且对其余结局指标无显著影响（证据质量为低或极低）。尽管术前暂停ACEIs/ARBs或可降低术中低血压发生率，但极低的证据质量提示未来仍需开展相关研究以明确其临床应用价值。本研究已在PROSPERO平台注册（CRD42021253965）。