Preoperative angiotensin-converting enzyme inhibitor use and its effect on intraoperative hypotension in non-cardiac surgeries: a meta-Analysis
Ahsan, Muhammad Nazmus Sakib, Abu Bakar Mohammad Mushtaq, Umer Mashayekhi, Yashar Khalid, Fajar Tariq, Muhammad Rohail Malik, Mohammad Faiq Hussain, Zeeshan Sarker, Piash Kazmi, Syed Imran Ahmed
Ahsan, Muhammad
Nazmus Sakib, Abu Bakar Mohammad
Mushtaq, Umer
Mashayekhi, Yashar
Khalid, Fajar
Tariq, Muhammad Rohail
Malik, Mohammad Faiq
Hussain, Zeeshan
Sarker, Piash
Kazmi, Syed Imran Ahmed
Abstract
Angiotensin-converting enzyme inhibitors (ACE inhibitors) are widely prescribed for cardiovascular and renal conditions, and a large proportion of patients presenting for non-cardiac surgery are chronic users of these agents. However, the optimal perioperative management of ACE inhibitors remains controversial, particularly regarding their association with intraoperative hypotension. This meta-analysis aimed to systematically evaluate the effect of preoperative ACE inhibitor use on intraoperative hypotension and related perioperative outcomes in adult patients undergoing non-cardiac surgery. A comprehensive literature search of major electronic databases was performed to identify randomized controlled trials and observational studies comparing continuation versus withholding of ACE inhibitors before non-cardiac surgery. Studies reporting intraoperative hypotension or related hemodynamic outcomes were included. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Heterogeneity was assessed using the I² statistic and Cochran's Q test. Five studies involving a total of 5,400 patients were included in the quantitative synthesis. Compared with continuation of ACE inhibitors, withholding these agents preoperatively was associated with a significantly lower incidence of intraoperative hypotension (pooled OR = 0.62, 95% CI: 0.52-0.74; p < 0.001), with moderate heterogeneity (I² = 41%). In addition, preoperative withholding of ACE inhibitors significantly reduced the requirement for intraoperative vasopressor support (pooled OR = 0.64, 95% CI: 0.52-0.80; p < 0.001), with low heterogeneity (I² = 24%). In contrast, no significant difference was observed between groups with respect to postoperative acute kidney injury (pooled OR = 0.92, 95% CI: 0.78-1.09; p = 0.33), and heterogeneity was negligible (I² = 0%). These findings indicate that withholding ACE inhibitors prior to non-cardiac surgery is associated with improved intraoperative hemodynamic stability and reduced vasopressor requirements, without a significant effect on postoperative acute kidney injury. Temporary preoperative discontinuation of ACE inhibitors may therefore be considered to minimize intraoperative hypotension in non-cardiac surgical patients, although individualized risk-benefit assessment remains essential.
MIDER Authors
Affiliations
Date
18/02/2026
Type
Article
Collections
Citation
Ahsan M, Nazmus Sakib ABM, Mushtaq U, Mashayekhi Y, Khalid F, Tariq MR, Malik MF, Hussain Z, Sarker P, Kazmi SIA. Preoperative Angiotensin-Converting Enzyme Inhibitor Use and Its Effect on Intraoperative Hypotension in Non-cardiac Surgeries: A Meta-Analysis. Cureus. 2026 Feb 18;18(2):e103846. doi: 10.7759/cureus.103846.