Preoperative N-terminal pro-B-type natriuretic peptide and myocardial injury after stopping or continuing renin-angiotensin system inhibitors in noncardiac surgery: a prespecified analysis of a phase 2 randomised controlled multicentre trial

Advancing surgical outcomes through cardiovascular biomarker sub-phenotyping

Recent findings from Gutierrez del Arroyo and colleagues identified distinct sub-phenotypes in patients undergoing major noncardiac surgery based on biomarkers such as N terminal pro-brain natriuretic peptide, renin, aldosterone, and angiotensin-converting enzyme 2, which were associated with varying risks of postoperative myocardial injury. Although their findings highlight the potential of sub-phenotyping for advancing perioperative precision medicine, further research is needed to validate these sub-phenotypes and explore their role in tailoring perioperative management strategies.

Continuation versus Discontinuation of Renin-Angiotensin System Inhibitors Before Noncardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

The optimal management of renin-angiotensin system inhibitors (RASIs) before noncardiac surgery remains unclear. Continuing RASIs may increase intraoperative hypotension, while discontinuation risks postoperative hypertension and heart failure. Current guidelines suggest withholding RASI 24 hours prior to surgery, but evidence is limited. This meta-analysis of randomized controlled trials aimed to clarify the risks and benefits of continuing versus withholding RASIs in this setting.

DESIGN

A systematic review of randomized clinical trials (RCTs) and meta-analysis.

SETTING

A comprehensive electronic search conducted in PubMed, Scopus, and Cochrane from inception to August 2024.

PARTICIPANTS

Nine clinical trials that collectively enrolled 8,906 patients undergoing noncardiac surgery.

INTERVENTIONS

A comparison of continuation versus discontinuation of RASIs preoperatively in patients undergoing noncardiac surgery.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were intraoperative hypotension, major adverse cardiovascular events (MACE), and all-cause mortality. Secondary outcomes included acute kidney injury (AKI) and postoperative hypertension. Patients who discontinued RASIs had a significantly lower incidence of intraoperative hypotension (risk ratio [RR], 0.66; 95% confidence interval [CI], 0.52-0.84) compared to those who continued treatment. No significant differences were observed in all-cause mortality (RR, 0.85; 95% CI, 0.40-1.85), MACE (RR, 1.01; 95% CI, 0.87-1.17), AKI (RR, 0.98; 95% CI, 0.79-1.22), and postoperative hypertension (RR, 1.57; 95% CI, 0.92-2.68).

CONCLUSIONS

Continuation of RASIs significantly increased the risk of intraoperative hypotension compared to discontinuation of treatment. Overall, no significant differences were observed in all-cause mortality, MACE, AKI, or postoperative hypertension between patients who continued or discontinued RASIs preoperatively.

Management of renin-angiotensin system inhibitors prior to major surgery: insights from the STOP-or-NOT trial

Strong recommendations on how to manage renin-angiotensin system inhibitors, including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, before surgery are lacking because of a lack of evidence, which is mostly limited to data from observational studies. The STOP-or-NOT trial was a large multicentre randomised trial designed to determine whether chronic renin-angiotensin system inhibitors should be continued or discontinued before major noncardiac surgery. As principal investigators of the STOP-or-NOT trial, we discuss the trial's results and how they contribute to the existing literature on management of renin-angiotensin system inhibitors before surgery.

Accurate diagnosis of heart failure and improved perioperative outcomes

With an ageing world population and increasing prevalence, heart failure is increasingly frequent as a comorbidity in operative patients, and its accurate preoperative diagnosis is essential to improve postoperative prognosis in patients undergoing noncardiac surgery. Use of electronic health records to assist in the accuracy of diagnosis and definition of an adjudicated heart failure reference standard could help guide intraoperative practice and improve outcomes in patients with heart failure.

Should renin-angiotensin system inhibitors be held prior to major surgery?

Many patients undergoing surgical procedures have a history of hypertension, diabetes mellitus, heart failure, or a combination. Often, these conditions involve the chronic use of a renin-angiotensin system inhibitor, including angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). Observational studies have suggested that continuing ACEIs/ARBs before major noncardiac surgery can increase the risk of intraoperative hypotension, which might drive postoperative complications such as acute kidney injury, myocardial injury, or stroke. Strong recommendations on how to manage ACEIs/ARBs before surgery are, however, lacking owing to insufficient evidence, mostly limited to data from observational studies. Recently, the SPACE trial investigated the impact of preoperative management of ACEIs/ARBs on postoperative myocardial injury. Myocardial injury occurred in 48.3% patients randomised to discontinue and 41.3% patients randomised to continue ACEI/ARB (odds ratio for continuing: 0.77, 95% confidence interval 0.45-1.31). Patients randomised to the 'Stop' group experienced more postoperative hypertension. In a post hoc analysis, patients randomised to the 'Continue' group with low preoperative NT-proBNP concentrations (<100 pg ml-1) experienced less myocardial injury after surgery than the 'Stop' group, whereas no significant difference was observed in patients with elevated preoperative NT-proBNP concentrations. The SPACE trial provides important and new reassuring data on the safety of continuing ACEIs/ARBs before major surgery, challenging previous beliefs.