• Matthieu Legrand, Jérémy Falcone, Bernard Cholley, Hélène Charbonneau, Amélie Delaporte, Adrien Lemoine, Matthias Garot, Alexandre Joosten, Claude Meistelman, Delphine Cheron-Leroy, Jean-Philippe Rives, Bruno Pastene, Antoine Dewitte, Stéphanie Sigaut, Danguy des DesertsMarcMDepartment of Anesthesia and Intensive Care, Clermont-Tonnerre Military Hospital, Univ Brest, Inserm, UMR 1304-GETBO, Brest, France., Cyrille Truc, Matthieu Boisson, Sigismond Lasocki, Philippe Cuvillon, Ugo Schiff, Samir Jaber, Morgan Le Guen, Anaïs Caillard, Stéphane Bar, Edmundo Pereira de Souza Neto, Vincent Colas, Florin Dimache, Thibaut Girardot, Elsa Jozefowicz, Simon Viquesnel, Francis Berthier, Eric Vicaut, Etienne Gayat, and Stop-or-Not Trial Group.
• Department of Anesthesiology and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco.
• JAMA. 2024 Sep 24; 332 (12): 970978970-978.

ImportanceBefore 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.ObjectiveTo 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 ParticipantsRandomized 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.InterventionPatients 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 MeasuresThe 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.ResultsOf 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 RelevanceAmong 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 RegistrationClinicalTrials.gov Identifier: NCT03374449.

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