Continuation vs Discontinuation of Renin-Angiotensin System Inhibitors Before Major Noncardiac Surgery: The Stop-or-Not Randomized Clinical Trial

Abstract

Importance: Before surgery, the best strategy for managing patients who are taking renin-angiotensin system inhibitors (RASIs) (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) is unknown. The lack of evidence leads to conflicting guidelines.

Objective: To evaluate whether a continuation strategy vs a discontinuation strategy of RASIs before major noncardiac surgery results in decreased complications at 28 days after surgery.

Design, setting, and participants: Randomized clinical trial that included patients who were being treated with a RASI for at least 3 months and were scheduled to undergo a major noncardiac surgery between January 2018 and April 2023 at 40 hospitals in France.

Intervention: Patients were randomized to continue use of RASIs (n = 1107) until the day of surgery or to discontinue use of RASIs 48 hours prior to surgery (ie, they would take the last dose 3 days before surgery) (n = 1115).

Main outcomes and measures: The primary outcome was a composite of all-cause mortality and major postoperative complications within 28 days after surgery. The key secondary outcomes were episodes of hypotension during surgery, acute kidney injury, postoperative organ failure, and length of stay in the hospital and intensive care unit during the 28 days after surgery.

Results: Of the 2222 patients (mean age, 67 years [SD, 10 years]; 65% were male), 46% were being treated with angiotensin-converting enzyme inhibitors at baseline and 54% were being treated with angiotensin receptor blockers. The rate of all-cause mortality and major postoperative complications was 22% (245 of 1115 patients) in the RASI discontinuation group and 22% (247 of 1107 patients) in the RASI continuation group (risk ratio, 1.02 [95% CI, 0.87-1.19]; P = .85). Episodes of hypotension during surgery occurred in 41% of the patients in the RASI discontinuation group and in 54% of the patients in the RASI continuation group (risk ratio, 1.31 [95% CI, 1.19-1.44]). There were no other differences in the trial outcomes.

Conclusions and relevance: Among patients who underwent major noncardiac surgery, a continuation strategy of RASIs before surgery was not associated with a higher rate of postoperative complications than a discontinuation strategy.

Trial registration: ClinicalTrials.gov Identifier: NCT03374449.

Figure 1.. Patient Selection, Randomization, and Flow Through the Trial

^aStratified by hospital site and history of chronic heart failure status (New York Heart Association stage <II or ≥II).

Figure 2.. Primary Outcome for All Patients and by Individual Patient Subgroups

The primary outcome was a composite of all-cause mortality and major postoperative complications (including major cardiovascular events, sepsis or septic shock, respiratory complications, unplanned intensive care unit admission or readmission, acute kidney injury, hyperkalemia, and need for surgical reintervention) within 28 days after surgery.

Figure 3.. Cumulative Incidence of the Primary Outcome by Treatment Group

The primary outcome was a composite of all-cause mortality and major postoperative complications (including major cardiovascular events, sepsis or septic shock, respiratory complications, unplanned intensive care unit admission or readmission, acute kidney injury, hyperkalemia, or need for surgical reintervention) within 28 days after surgery. The hash marks indicate censoring. The median follow-up was 28 days (IQR, 28-31 days).