Recent peri-operative guidelines recommending the continuation of ACE inhibitors and ARBs lack adequate trial data for heart failure patients and conflict with standard NICE initiation criteria.
Should antihypertensives, including ACE inhibitors and ARBs, be continued peri-operatively in all patients, including those with heart failure?
This editorial highlights uncertainties in recent guidelines regarding the peri-operative continuation of ACE inhibitors and ARBs, particularly in patients with heart failure, and questions the management of ARNIs and alignment with NICE guidelines.
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A recommendation in the hypertension guidelines from the Association of Anaesthetists and British and Irish Hypertension Society advises to continue all antihypertensives peri-operatively, including angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers 1. Whilst this has been a much-debated topic in the literature, it is nonetheless a significant change to current practice. We wish to highlight the following three points. First, is the recommendation to routinely continue these drugs applicable to all indications, including patients with heart failure? There is no mention of ‘heart failure’ in the main article, but the supporting information file states “similarly, if concomitant heart failure is present and stable, peri-operative continuation of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be considered”. This cites the 2022 European Society of Cardiology guidelines, yet whilst these recommend discontinuing these drugs peri-operatively in patients without heart failure, they make no explicit recommendation about continuing or discontinuing in patients with heart failure. This is possibly because they noted low numbers of patients with heart failure in the clinical trials available at the time of publication 2. The recommendation to continue ACE inhibitors and angiotensin receptor blockers peri-operatively is based on the findings from the SPACE and STOP-or-NOT trials published in 2023 and 2024, respectively 3, 4. Legrand et al. acknowledge the findings of the STOP-or-NOT trial might not be transferable to patients with heart failure due to the low prevalence (6%) of patients in each group 4. Similarly, the SPACE trial recruited limited patients with heart failure; 4.6% in the continuation group and 7.9% in the discontinuation group 3. Second, what is the position of the Working Party on the peri-operative management of angiotensin receptor neprilysin inhibitors? The supporting information file states “renin inhibitors (e.g. aliskiren) and angiotensin receptor-neprilysin inhibitors (e.g. sacubitril/valsartan) are recommended to be held on day of surgery due to the risk of profound intra-operative hypotension”. This cites the Society for Perioperative Assessment and Quality Improvement (SPAQI) guidelines from 2022, which predate publication of the STOP-or-NOT trial and recommend peri-operative discontinuation of ACE inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors and renin inhibitors. The European Society of Cardiology highlights the absence of data on the peri-operative effects of angiotensin receptor neprilysin inhibitors, but states that hypotension is more common than in patients on ACE inhibitors 2. If the recommendation is for peri-operative discontinuation of angiotensin receptor neprilysin inhibitors, is this only the dose on the morning of surgery (as recommended by SPAQI), is it for 24 h pre-operatively or is it both doses on the day of surgery? Third, should pre-operative initiation of antihypertensive therapy be indicated, why do the recommendations for treatment not align with clinical guidelines from the National Institute for Health and Care Excellence? Specifically, recommendations on calcium channel blockers as first-line treatment in patients who do not have type 2 diabetes mellitus and who are either aged > 55 y or of Black African or African-Caribbean origin. The National Institute for Health and Care Excellence recommend ACE inhibitors as first-line treatment for patients with type 2 diabetes mellitus who are any age or family origin and for patients aged < 55 y providing they are not of Black African or African-Caribbean origin 5. However, the new peri-operative guidelines recommend calcium channel blockers as first-line treatment for all adults 1. Similarly, if a second drug is required, the guidelines recommend the addition of an angiotensin receptor blocker rather than an ACE inhibitor. Yet the National Institute for Health and Care Excellence recommends either an ACE inhibitor or angiotensin receptor blocker in patients already taking a calcium channel blocker 5. If the treatment recommendation in the peri-operative guidelines is based on time to clinical effect, are there any clinical trial data to support this?
C. B. Frank (Thu,) reported a other. Recent peri-operative guidelines recommending the continuation of ACE inhibitors and ARBs lack adequate trial data for heart failure patients and conflict with standard NICE initiation criteria.