Con: ACE inhibitors should be stopped prior to cardiovascular operations

THE PERIOPERATIVE administration of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs) in patients undergoing cardiac surgery is fraught with controversy; there are no established guidelines regarding their preoperative use. While there is definitive evidence for the long-term benefits of ACEI (eg, patients status post-myocardial infarction [MI], patients with congestive heart failure [CHF], and patients with chronic kidney disease), preoperative ACEI administration for cardiac surgical patients may lead to worse outcomes. 1 Hasija S. Makhija N. Hote M. et al. Prophylactic vasopressin in patients receiving the angiotension-converting enzyme inhibitor ramipril undergoing coronary artery bypass graft surgery. J Cardiothoracic Vasc Anesth. 2010; 24: 230-238 Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar , 2 Bainey K.R. Armstrong P.W. Fonarow G.C. et al. Use of renin-angiotensin system blockers in acute coronary syndromes: Findings from Get With the Guidelines-Coronary Artery Disease Program. Circ Cardiovasc Qual Outcomes. 2014; 7: 227-235 Crossref PubMed Scopus (10) Google Scholar , 3 Zhang Y. Ma L. Effect of preoperative angiotensin-converting enzyme inhibitor on the outcome of coronary artery bypass graft surgery. Eur J Cardiothorac Surg. 2015; 47: 788-795 Crossref PubMed Scopus (18) Google Scholar In patients undergoing cardiac surgery, preoperative administration of renin-angiotensin system (RAS) inhibitors is associated with acute kidney injury (AKI), vasoplegia, atrial fibrillation (AF), and increased mortality.