Choice to halt RAS therapy before major surgery can be left to patient, physician
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Key takeaways:
- Discontinuation of RAS therapy before major noncardiac surgery did not impact postoperative outcomes vs. continuation.
- Continuation or discontinuation of RAS inhibition ahead of major surgery is “acceptable.”
Discontinuation of renin-angiotensin system inhibitor therapy before major noncardiac surgery did not appear to affect postoperative outcomes vs. treatment continuation, a speaker reported.
The results of the STOP-or-NOT trial were presented at the European Society of Cardiology Congress and simultaneously published in JAMA.
“Major noncardiac surgeries are being performed on more than 300 million people per year and postoperative mortality is the third leading cause of death,” Matthieu Legrand, MD, PhD, professor of anesthesia at the University of California, San Francisco, said during a press conference. “Among patients undergoing major noncardiac surgery, more than 50% have a chronic treatment with renin-angiotensin system (RAS) inhibitors — referring to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers — because of hypertension, diabetes or heart failure. Continuation vs. discontinuation of these medications before surgery may have an impact on outcome, but the best strategy is unknown and guidelines are conflicting.”
For the multicenter, randomized controlled STOP-or-NOT trial, Legrand and colleagues evaluated the impact of RAS discontinuation before major noncardiac surgery on 28-day all-cause mortality and major postoperative complications.
Overall, 2,222 patients were randomly assigned to discontinue RAS inhibition 48 hours before surgery or to continue the drug until the day of surgery (mean age, 67 years; 65% men). Forty-eight percent of the cohort was treated with ACE inhibitors and 54% was treated with ARBs at baseline, according to the simultaneous publication.
The most prevalent surgeries were abdominal in nature, followed by thoracic, vascular, urological, orthopedic, pelvic, neurosurgical and liver surgeries.
At 28 days, the rate of all-cause mortality and major postoperative complications was not significantly different between participants who halted RAS therapy before surgery and those who did not, at 22% in both groups (risk ratio = 1.02; 95% CI, 0.87-1.19; P = .85).
The researchers reported a lower rate of hypotension episodes during surgery in the RAS discontinuation group compared with the continuation group (41% vs. 54%; RR = 1.31; 95% CI, 1.19-1.44), but there were no other significant differences between the two groups.
“A renin-angiotensin system inhibitors continuation strategy before major noncardiac surgery was not associated with a higher rate of postoperative complication than a discontinuation strategy,” Legrand said during the press conference. “Based on these results, we might consider that both strategies appear to be acceptable and a clinician may have greater flexibility in managing RAS therapies based on individual patient factors and the specific surgery and also the patient’s preference.”
Reference:
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Legrand M. Hot line 1. Presented at: European Society of Cardiology Congress; Aug. 30-Sept. 2, 2024; London (hybrid meeting).
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