Perioperative management of renin–angiotensin system inhibitors in patients undergoing elective major noncardiac surgery: a mixed model investigation using systematic review, meta-analysis, multicentre service evaluation, and national survey

Giannas, E; Patel, A; Dias, P; Heath, RJ; Sinclair, R; Surman, K; Milton, A; Middleditch, A; Abbott, TEF; Ackland, GL; Pearse, RM; Janssen, H; contributors

doi:10.1016/j.bja.2025.06.026

Perioperative management of renin–angiotensin system inhibitors in patients undergoing elective major noncardiac surgery: a mixed model investigation using systematic review, meta-analysis, multicentre service evaluation, and national survey

Br J AnaesthPublished 31 Jul 2025Systematic review and meta-analysis of randomised trials, with multicentre service evaluation and national survey

Pooled resultResultOdds ratio 1.21 CI 0.60–2.42

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Authors' conclusion

The optimal approach to perioperative RAS inhibitor use remains uncertain. Although UK clinicians often withhold these drugs, this strategy could cause harm.

Study context

Population: Patients undergoing elective major noncardiac surgery taking renin-angiotensin system (RAS) inhibitors
Participants: 2,848 patients · 5 randomised controlled trials (RCTs)

Comparison: Stopping vs continuing RAS inhibitors before major noncardiac surgery
Outcome: Composite of:
Mortality
MACE

Methodological detailsrandom effects models, prospective service evaluation, clinician survey, Searched MEDLINE, CINAHL, ProQuest, Cochrane, Scopus, Web of Science, January 2000 to October 2024

Random effects models
Prospective service evaluation
Clinician survey
Searched MEDLINE, CINAHL, ProQuest, Cochrane, Scopus, Web of Science, January 2000 to October 2024

Pooled result

As reported in the abstract

Odds ratio

1.21

CI 0.60–2.42

P = 0.59

Stopping vs Continuing

OR 1.21 (CI 0.60–2.42); P = 0.59

Further pooled results

Outcome	← Lower odds with stopping ←→ Higher odds with stopping →	OR (CI)	P value
Acute hypertensionI2=8%	0.20.5125	1.90 (1.20–3.02)	P = 0.007
Hypotension eventsI2=38%	0.20.5125	0.62 (0.42–0.90)	P = 0.01
	0.20.5125Odds ratio (log scale)

UK service evaluation: RAS inhibitors stopped (316 patients, 7 hospitals)

RAS inhibitors stopped: 248/316 (79%)
Restarted within 48 h after surgery, of those stopped: 230/248 (93%)

Clinician survey: clinicians asking patients to stop RAS inhibitors before surgery

Clinicians asking patients to stop: >80%

Variable reasons concerning risks and benefits

Original publication

Perioperative management of renin–angiotensin system inhibitors in patients undergoing elective major noncardiac surgery: a mixed model investigation using systematic review, meta-analysis, multicentre service evaluation, and national survey. Br J Anaesth. Published 31 July 2025. doi:10.1016/j.bja.2025.06.026

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