A continuation strategy of renin-angiotensin system inhibitors (RASIs) before major noncardiac surgery was associated with better post-operative outcomes than discontinuation, based on results from the Stop-or-Not trial presented at ESC Congress 2024 and simultaneously published in JAMA.

The trial conducted in 41 centers in France randomized 2,222 patients to either continue RASIs until the day of major elective noncardiac surgery or discontinue them 48 hours prior to the procedure. The mean age of patients was 67 years and 65% were male. At baseline, 98% percent of patients were treated for hypertension, 9% had chronic kidney disease, 8% had diabetes, 4% had heart failure, 46% were treated with ACEIs and 54% were treated with ARBs. In both groups, it was recommended that RASIs resume as soon as possible after surgery.

Overall results found that the rates of post-operative major cardiovascular events within 28 days after surgery were the same (22%) across both the discontinuation and continuation groups. Researchers noted that the effect of discontinuation vs. continuation of RASIs on the risk of post-operative complications was consistent across subgroups. In addition, episodes of hypotension during surgery occurred in 41% of patients in the discontinuation group compared with 54% of patients in the continuation group.

According to the study investigators, the finding could have an effect on future guidelines. "Results from the Stop-or-Not trial may now be used within guideline recommendations, which are generally weak," said Principal Investigator Matthieu Legrand, MD. "Given the lack of difference, both strategies appear acceptable, indicating that a tailored approach to RASI continuation could be used. A discontinuation strategy may be considered if there is a particular concern for hypotension, while continuation may be preferred in patients who are worried about stopping their medication or for practical purposes."