Abstract
PurposeThis trial was conducted to compare effects of continuing versus withholding single-pill combination tablets consisting of angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) on perioperative hemodynamics and clinical outcomes.MethodsPatients undergoing minor abdominal or urological surgery (n = 106) were randomly assigned to Group C, in which ARB/CCB combination tablets were continued until surgery, or Group W, in which they were withheld within 24 h of surgery. Perioperative hemodynamics and clinical outcomes were compared between the Groups.ResultsThe incidence of hypotension during anesthesia requiring repeated treatment with vasoconstrictors was higher in Group C than Group W (p = 0.0052). Blood pressure during anesthesia was generally lower in Group C than Group W (p < 0.05) despite significantly more doses of ephedrine and phenylephrine administrated in Group C (p = 0.0246 and p = 0.0327, respectively). The incidence of postoperative hypertension did not differ between Groups (p = 0.3793). Estimated glomerular filtration rate (eGFR) on the preoperative day did not differ between Groups (p = 0.7045), while eGFR was slightly lower in Group C than Group W on the first and third postoperative days (p = 0.0400 and p = 0.0088, respectively), although clinically relevant acute kidney injury did not develop.ConclusionsContinuing ARB/CCB combination tablets preoperatively in patients undergoing minor surgery increased the incidence of hypotension during anesthesia, increased requirements of vasoconstrictors to treat hypotension, and might deteriorate postoperative renal function, albeit slightly. These results suggest that withholding ARB/CCB tablets preoperatively is preferable to continuing them.Clinical trial registrationThis trial is registered with the Japan Registry of Clinical Trials (jRCT) at Japanese Ministry of Health, Labour, and Welfare (Trial ID: jRCT1031190027).
Highlights
Regarding angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), the 2014 American Heart Association (AHA) guideline recommends that continuation of ACEIs and Angiotensin receptor blocker (ARB) in the immediate preoperative period is reasonable [11], whereas the 2014 European Society of Cardiology (ESC) guidelines recommends transient discontinuation of ACEIs and ARBs before surgery [12], mainly based on the identical data showing that their continuation does not worsen patients’ outcomes, it increases the risk of intraoperative hypotension [13, 14], as confirmed by a later meta-analysis [15]
Patients were randomly assigned to either continuing drug group (Group C), in which ARB/calcium channel blockers (CCBs) combination tablets were continued until the evening before surgery or the morning of surgery, or withholding drug group (Group W), in which ARB/CCB combination tablets were withheld within 24 h of surgery, using the envelope method applied separately to patients scheduled for abdominal surgery and those scheduled for urological surgery
The incidence of hypotension during anesthesia defined as systolic BP (SBP) < 80 mmHg requiring treatment with vasoconstrictors at least once did not differ between the Groups
Summary
Hypertension is a common condition affecting a significant percentage of populations. In patients with hypertension undergoing elective surgery, it is considered reasonable to continue medical therapy for hypertension until surgery [2]. Regarding CCBs, it has been considered reasonable to continue them until surgery [5, 6], as CCBs do not induce exaggerated hypotension during anesthesia [7, 8], and CCBs may improve patients’ postoperative outcomes [9, 10]. After publication of a large-scale observational cohort study showing that continuing ACEIs and ARBs perioperatively may worsen clinical outcomes in patients undergoing noncardiac surgery [16], recent reviews and guidelines tend to recommend withholding ACEIs/ARBs [6, 17], it may be required to restart ACEIs/ARBs after surgery as soon as possible because delayed or omitted reinstitution may worsen clinical outcomes [6, 18, 19]
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