Impact of Renin-Angiotensin System Inhibitors Continuation on Outcome After Major Surgery - Stop-or-Not

Aug 30, 2024
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Kim A. Eagle, MD, MACC
Trial Sponsor:
French Ministry of Health
Date Presented:
08/30/2024
Date Published:
08/30/2024
Original Posted Date:
08/30/2024
References

Contribution To Literature:

The Stop-or-Not trial showed that discontinuation of renin-angiotensin system inhibitors before major noncardiac surgery does not improve outcomes.

Description:

The goal of the trial was to evaluate discontinuation of renin-angiotensin system inhibitors compared with continuation before major noncardiac surgery.

Study Design

  • Randomized
  • Parallel

Patients on a renin-angiotensin system inhibitor and undergoing major noncardiac surgery were randomized to discontinuation (n = 1,115) versus continuation of this medication 48 hours before surgery (n = 1,107).

  • Total number of enrollees: 2,222
  • Duration of follow-up: 28 days
  • Median patient age: 68 years
  • Percentage female: 35%
  • Percentage with diabetes: 8%

Inclusion criteria:

  • Undergoing major noncardiac surgery
  • Use of a renin-angiotensin system inhibitor within the last 3 months

Exclusion criteria:

  • Emergency surgery
  • Hyperkalemia
  • Terminal illness
  • Severe renal insufficiency
  • Preoperative shock
  • Lack of insurance

Principal Findings:

The primary outcome, all-cause mortality, major cardiovascular events, sepsis, septic shock, respiratory complications, or unplanned management in the intensive care unit, was 22% in the discontinuation group vs. 22% in the continuation group (p = not significant).

Secondary outcomes:

  • Hypotension requiring treatment: 41% in the discontinuation group vs. 54% in the continuation group
  • Duration of hypotension: 6 minutes in the discontinuation group vs. 9 minutes in the continuation group

Interpretation:

Among patients undergoing major noncardiac surgery, discontinuation of renin-angiotensin system inhibitors 48 hours before surgery did not improve outcomes. Continuation of renin-angiotensin system inhibitors was associated with hypotension; however, this was a short duration and did not increase adverse events. Discontinuation of renin-angiotensin system inhibitors before major noncardiac surgery has been endorsed by anesthesia guidelines; however, this practice was mainly based on observational studies. Based on the results of this trial, continuation of renin-angiotensin system inhibitors before surgery can now be considered.

References:

Legrand M, Falcone J, Cholley B, et al., for the Stop-or-Not Trial Group. Continuation vs Discontinuation of Renin-Angiotensin System Inhibitors Before Major Noncardiac Surgery: The Stop-or-Not Randomized Clinical Trial. JAMA 2024;Aug 30:[Epub ahead of print].

Presented by Dr. Matthieu Legrand at the European Society of Cardiology Congress, London, UK, August 30, 2024.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Angiotensin Receptor Antagonists, Heart Failure, Perioperative Care, Renin-Angiotensin System, ESC24, ESC Congress


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