Prospective randomized evaluation of preoperative angiotensin-converting enzyme inhibition (PREOP-ACEI)

Jason F. Shiffermiller, Benjamin J. Monson, Chad W. Vokoun, Micah W. Beachy, Michael P. Smith, James N. Sullivan, Andrew J. Vasey, Purnima Guda, Elizabeth R. Lyden, Sheila J. Ellis, Huiling Pang, Rachel E Thompson

Research output: Contribution to journalArticlepeer-review

23 Scopus citations


BACKGROUND: Intraoperative hypotension is associated with an increased risk of end organ damage and death. The transient preoperative interruption of angiotensin-converting enzyme inhibitor (ACEI) therapy prior to cardiac and vascular surgeries decreases the occurrence of intraoperative hypotension. OBJECTIVE: We sought to compare the effect of two protocols for preoperative ACEI management on the risk of intraoperative hypotension among patients undergoing noncardiac, nonvascular surgeries. DESIGN: Prospective, randomized study. SETTING: Midwestern urban 489-bed academic medical center. PATIENTS: Patients taking an ACEI for at least six weeks preoperatively were considered for inclusion. INTERVENTIONS: Randomization of the final preoperative ACEI dose to omission (n = 137) or continuation (n = 138). MEASUREMENTS: The primary outcome was intraoperative hypotension, which was defined as any systolic blood pressure (SBP) < 80 mm Hg. Postoperative hypotensive (SBP < 90 mm Hg) and hypertensive (SBP > 180 mm Hg) episodes were also recorded. Outcomes were compared using Fisher’s exact test. RESULTS: Intraoperative hypotension occurred less frequently in the omission group (76 of 137 [55%]) than in the continuation group (95 of 138 [69%]) (RR: 0.81, 95% CI: 0.67 to 0.97, P = .03, NNH 7.5). Postoperative hypotensive events were also less frequent in the ACEI omission group (RR: 0.49, 95% CI: 0.28 to 0.86, P = .02) than in the continuation group. However, postoperative hypertensive events were more frequent in the omission group than in the continuation group (RR: 1.95, 95%: CI: 1.14 to 3.34, P = .01). CONCLUSION: The transient preoperative interruption of ACEI therapy is associated with a decreased risk of intraoperative hypotension. REGISTRATION: NCT01669434.

Original languageEnglish (US)
Pages (from-to)661-667
Number of pages7
JournalJournal of Hospital Medicine
Issue number10
StatePublished - Oct 2018

ASJC Scopus subject areas

  • Internal Medicine
  • Leadership and Management
  • Fundamentals and skills
  • Health Policy
  • Care Planning
  • Assessment and Diagnosis


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