Stopping versus continuing renin-angiotensin system inhibitors before surgery: An updated systematic review and meta-analysis of randomised controlled trials

Background and Aims: The optimal perioperative management of patients chronically using renin-angiotensin system inhibitors (RASIs) is still uncertain. This study aims to compare the outcomes of withholding versus continuing RASIs before surgery, focusing on efficacy and safety. Methods: A systematic review and meta-analysis synthesising evidence from randomised controlled trials (RCTs) obtained from PubMed, CENTRAL, Scopus, and Web of Science until September 2024. Using Stata MP v. 17, we used the fixed-effects model to report dichotomous outcomes by using the risk ratio (RR) with a 95% confidence interval (CI). Results: Ten RCTs with 3,740 patients were included. There was no statistical difference between both groups regarding the incidence of major adverse cardiac events (MACE) [Risk ratio (RR): 0.99; 95% confidence interval (CI): 0.84, 1.16; P = 0.88], all-cause mortality (RR: 0.88; 95% CI: 0.44, 1.78; P = 0.72), myocardial infarction (MI) (RR: 1.67; 95% CI: 0.61, 4.58; P = 0.32), heart failure/acute pulmonary oedema (RR: 1.87; 95% CI: 0.51, 6.84; P = 0.34), stroke (RR: 1.22; 95% CI: 0.35, 4.24; P = 0.75), postoperative hypotension (RR: 0.85; 95% CI: 0.66, 1.10; P = 0.22), perioperative hypertension (RR: 1.21; 95% CI: 1.00, 1.46; P = 0.05), and acute kidney injury (AKI) (RR: 1.01; 95% CI: 0.80, 1.26; P = 0.97). However, withholding RASIs was significantly associated with a decreased incidence of intraoperative hypotension (RR: 0.82; 95% CI: 0.75, 0.89; P < 0.001). Conclusion: Stopping RASIs in patients undergoing surgery was not associated with a higher risk of postoperative complications, such as MACE, all-cause mortality, myocardial infarction, heart failure/acute pulmonary oedema, stroke, or AKI. Conversely, discontinuing RASIs notably reduced the incidence of intraoperative hypotension.