Should ACE Inhibitors and ARBs Be Continued Perioperatively?

Many primary care physicians, hospitalists, cardiologists, and anesthesiologists hold certain blood pressure (BP) medications — specifically angiotensin-converting–enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) — perioperatively (i.e., day of surgery and immediate postoperatively). This practice is based on studies that showed higher rates of intraoperative hypotension and risk for adverse events when these drugs are continued on the day of surgery (NEJM JW Gen Med Feb 1 2017 and Anesthesiology 2017; 126:16) and on guidelines that recommend withholding these medications (low-quality evidence; Can J Cardiol 2017; 33:17).

The POISE-3 trial, published in 2023, involved 7500 hypertensive patients, most of whom were taking ACE i…