BACKGROUND:

The optimal management of angiotensin-converting enzyme (ACE) inhibitors during elective surgeries remains uncertain. While some studies suggest that continuing ACE inhibitors increase the risk of perioperative hypotension, others argue that discontinuation may heighten the risk of significant clinical events. This meta-analysis aims to clarify the clinical outcomes associated with continuation compared to discontinuation of ACE inhibitors in surgical settings.

METHODS:

We conducted a systematic search of MEDLINE, Cochrane, and Embase for clinical trials comparing the effects of continuing versus discontinuing ACE inhibitors during surgery. Outcomes evaluated included death, stroke, myocardial injury (MI), intraoperative hypotension, postoperative hypotension, and acute kidney injury (AKI). Data were synthesized using odds ratios (OR) with 95% confidence intervals (CI). Heterogeneity was assessed with I2 statistics, and a random-effects model was applied. Statistical analyses were performed using R software version 4.3.2.

RESULTS:

From 865 identified studies, 15 studies involving 11,519 patients met the inclusion criteria. Not all studies had outcomes available for comparison between them. The average age was 65.75 years, with 86.45% having hypertension and 13.13% with heart failure. Continuing ACE inhibitors was associated with a higher risk of intraoperative hypotension (OR 1.33; 95% CI 1.16-1.53). No significant differences were found between groups for mortality (OR 1.06; 95% CI 0.68-1.65), stroke (OR 0.99; 95% CI 0.47-2.09), MI (OR 0.98; 95% CI 0.72-1.31), postoperative hypotension (OR 1.27; 95% CI 0.74-2.17), and AKI (OR 0.88; 95% CI 0.66-1.16).

CONCLUSION:

Discontinuation of ACE inhibitors before non-cardiac surgery may lower the risk of intraoperative hypotension without significantly affecting mortality, stroke, MI, postoperative hypotension, or AKI. Further research with greater power and better design is needed to confirm these findings.