ACE inhibitors are a commonly used antihypertensive medication, especially in patients with concomitant heart failure (to reduce maladaptive remodeling). ACE inhibitors are generally discontinued prior to planned surgical procedures requiring anesthesia due to the potential risk for refractory hypotension, or vasoplegic syndrome, requiring vasoactive agents. There have been several case reports for severe, even fatal, hypotension resulting from patients continuing their ACE/ARB and then receiving GA, spinal anesthesia, and GA supplemented with epidural anesthesia. This is likely due to increased reliance on the renin-angiotensin and vasopressor systems to maintain blood pressure when vascular tone is decreased following administration of anesthetics. A recent study demonstrated that patients who held their ACE inhibitor 24h prior to surgery were less likely to suffer a composite outcome of 30-day all-cause death, stroke, or MI. Ultimately, the decision on holding or continuing these medications is largely provider dependent and varies based on the patient’s clinical picture and co-morbid conditions.
Other potential side effects of ACE inhibitors include hyperkalemia, renal insufficiency, hypovolemia, dry cough, angioedema, fatigue, and others.
- Roshanov, Pavel S., et al. “Withholding versus Continuing Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery.”Anesthesiology, vol. 126, no. 1, 2017, pp. 16–27. Link
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