Continuing versus Withholding Renin–Angiotensin–Aldosterone System Antagonists Before Noncardiac Surgery: A Systematic Review and Meta-Analysis

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Published Nov 9, 2025
https://doi.org/10.62438/tunismed.v103i9.6236
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Vol. 103 No. 9 (2025): Tunis Med sept 2025

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Mohamed Aziz Daghmouri
Department of Anesthesiology, Montreuil Intercommunal Hospital Center, France
Faten Haddad
Department of Anesthesiology and Critical Care Medicine,Mongi Slim Teaching Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
Emna Kammoun
Department of Anesthesiology and Critical Care Medicine, Mongi Slim Teaching Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
Fathi Jebali
Department of Anesthesiology B, Monastir Teaching Hospital, University of Monastir, Monastir, Tunisia
Heithem Jeddou
Department of Hepatobiliary and Digestive Surgery, University Hospital, Inserm, EHESP, Irset (Institute for Research in Health, Environment and Work) - UMR_S 1085, Rennes 1 University, Rennes, France
Mohamed Ali Chaouch
Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia

Abstract

Background: It remains unclear whether to continue or withdraw angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEI) before noncardiac surgery to reduce perioperative morbidity. This systematic review and meta-analysis aimed to analyze the consequences of continuing ARB or ACEi in the incidence of intraoperative hypotension and postoperative complications.


Methods: This systematic review and meta-analysis followed the PRISMA 2020 guidelines and was registered in the PROSPERO database. We conducted a comprehensive search in several bibliographic databases for studies comparing continuing versus withholding renin angiotensin aldosterone system antagonists before noncardiac surgery. Primary outcomes included the incidence of intraoperative hypotension, while secondary outcomes covered the intraoperative use of the vasoactive agent, the incidence of severe hypotension, intraoperative and postoperative hypertension, the incidence of acute kidney injury (AKI), 30-day postoperative all-cause mortality, and the incidence of major cardiocerebral events (MACCE).


Results: Five randomized controlled trials, three nonrandomized controlled trials, and four retrospective case-control studies were included that involved 50184 patients. Meta-analysis revealed that continuing ACEI or ARBs before surgery increased the incidence of intraoperative hypotension (OR = 1.96, 95%CI [1.30, 2.96] p=0.001). Heterogeneity was substantial across studies but was significantly reduced in subgroup analyses. Furthermore, the use of vasoactive agents and the incidence of severe hypotension were significantly higher in the continuing group.  No significant differences in intraoperative hypertension and the incidence of AKI and MACCE at 30 days after the operation.


Conclusions: Continued ACEI or ARBs before non-cardiac surgery increases the incidence of intraoperative hypotension, without reducing the incidence of both AKI and MACCE postoperatively. More research is necessary to explore the appropriate perioperative management of ACE-I and ARB.

Keywords:

angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, noncardiac surgery, intraoperative hypotension

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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