Frequency of Intraoperative Hypotension After the Induction of Anesthesia in Hypertensive Patients with Preoperative Angiotensin-converting Enzyme Inhibitors

Fahad Salim, Fazal Khan, Muhammad Nasir, Rashid Ali, Ayesha Iqbal, Amir Raza, Fahad Salim, Fazal Khan, Muhammad Nasir, Rashid Ali, Ayesha Iqbal, Amir Raza

Abstract

Introduction The renin-angiotensin-aldosterone system (RAAS) is an important target in the treatment of hypertension. Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I to angiotensin II. ACE inhibitors not only treat hypertension but also decrease morbidity and mortality in heart failure patients and in patients with acute myocardial infarction. The discontinuation of ACE inhibitors before the surgery is still controversial. To assess the current magnitude of the problem in our population, we aimed to conduct this study, which evaluated the frequency of intraoperative hypotension after the induction of anesthesia in controlled hypertensive patients with preoperative ACE inhibitors. Material and methods This descriptive case series study was conducted at a tertiary hospital in a developing country after approval from the Ethics Review Committee. A total of 115 adult patients, from 16 to 60 years of age, who have undergone elective surgery, have controlled hypertension on the desired drugs for at least six months, have no history of any cardiac event, and have taken the drug on the morning of the surgery, were included in the study after written consent. The demographic data of the patients were entered into the proforma. Preoperative systolic, diastolic, and mean arterial pressure were recorded by the researcher or an assignee in the preoperative holding area. The patients were followed in the recovery room by the team conducting the study until 10 minutes after the arrival of the patient in the recovery room. All statistical analyses were performed using Statistical Packages for the Social Sciences version 19 (SPSS Inc., Chicago, IL). p-value ≤0.05 was considered significant. Results Of the 115 patients, 56 (48.7%) patients were in the age group between 51 and 60 years of age; 38 patients were between the ages of 41 and 50 years and only 21 patients were 40 years or less. On gender, 68 patients were female and 47 were male. According to body mass index (BMI), the majority of the patients were in the overweight group, amounting to 53 (46%), and 86 (74.78%) patients were known diabetics. Overall, 77 (66.96%) of the patients developed intraoperative hypotension with 41 (35.65%) patients requiring the use of vasopressors in order to correct the hypotension. No statistically significant difference was found between demographic and clinical variables. Conclusion Intraoperative hypotension is more frequent in patients with controlled hypertension on ACE inhibitors although more studies need to be conducted on a larger population in order to determine a more definitive result.

Keywords: ace inhibitors; anesthesia; angiotensin converting enzyme inhibitors; hypertension; hypotension.

Conflict of interest statement

The authors have declared that no competing interests exist.

Copyright © 2020, Salim et al.

References

    1. An encounter with enalapril-induced resistant, life-threatening angioedema at rural health center in Botswana. Anish N, Gabremedhin AM. Indian J Crit Care Med. 2016;20:613–616.
    1. Perioperative use of beta-blockers in vascular and endovascular surgery. Myles PS. Br J Anaesth. 2017;118:948–949.
    1. Pharmacologic and perioperative considerations for antihypertensive medications. Pai S-L, Chadha RM, Irizarry-Alvarado JM, Renew JR, Aniskevich I. Curr Clin Pharmacol. 2017;12:135–140.
    1. Pharmacologic myocardial protection in patients undergoing noncardiac surgery: a quantitative systematic review. Stevens RD, Burri H, Tramer MR. Anesth Analg. 2003;97:623–633.
    1. Patterns of use of perioperative angiotensin-converting enzyme inhibitors in coronary artery bypass graft surgery with cardiopulmonary bypass. Effects on in-hospital morbidity and mortality. Drenger B, Fontes ML, Miao Y, et al. Circulation. 2012;17:261–269.
    1. Angiotensin-converting enzyme inhibition and blood pressure response during total intravenous anaesthesia for minor surgery. Schulte E, Ziegler D, Philippi-Hohne C, Kaczmarczyk G, Boemke W. Acta Anaesthesiol Scand. 2011;55:435–443.
    1. Refractory hypotension during general anesthesia despite preoperative discontinuation of an angiotensin receptor blocker. Nabbi R, Woehlck HJ, Riess ML. F1000Res. 2013;2:12.
    1. Hemodynamic effects of anesthesia in patients with ischemic heart failure chronically treated with angiotensin-converting enzyme inhibitors. Ryckwaert F, Colson P. . Anesth Analg. 1997;84:945–949.
    1. Beta-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors and angiotensin receptor blockers: should they be stopped or not before ambulatory anaesthesia. Smith I, Jackson I. Curr Opin Anaesthesiol. 2010;23:687–690.
    1. Influence of chronic angiotensin-converting enzyme inhibition on anesthetic induction. Coriat P, Richer C, Douraki T, et al. Anesthesiology. 1994;81:299–307.
    1. Intra-operative hypotension. Induction of anesthesia in patients continuing their routine dose of angiotensin system inhibitor therapy before surgery. Khan MA, Shujaat S, Iqbal MR, Hanif MD, Ahmed A. Professional Med J. 2012;19:695–699.
    1. Perioperative use of renin-angiotensin system inhibitors and outcomes in patients undergoing cardiac surgery. Ding Q, Zhang Z, Liu H, et al. Nat Commun. 2019;10:1–10.
    1. Angiotensin-converting enzyme inhibitors: mechanisms of action and implications in anesthesia practice. Behnia R, Molteni A, Igic R. Curr Pharm Des. 2003;9:763–776.
    1. Effect of omitting regular ACE inhibitor medication before cardiac surgery on haemodynamic variables and vasoactive drug requirements. Pigott DW, Nagle C, Allman K, Westaby S, Evans RD. Br J Anaesth. 1999;83:715–720.
    1. Angiotensin system inhibitors in a general surgical population. Comfere T, Sprung J, Kumar MM, et al. Anesth Analg. 2005;100:636–644.
    1. Effect of pre-operative discontinuation of angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists on intra-operative arterial pressures after induction of general anesthesia. Rajgopal R, Rajan S, Sapru K, Paul J. Anesth Essays Res. 2014;8:32–35.
    1. Hemodynamic effects of anesthesia in patients chronically treated with angiotensin-converting enzyme inhibitors. Colson P, Saussine M, Séguin JR, Cuchet D, ChaptalG PA, Roquefeuil B. Anesth Analg. 1992;74:805–808.
    1. Chronic angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy combined with diuretic therapy is associated with increased episodes of hypotension in noncardiac surgery. Kheterpal S, Khodaparast O, Shanks A, O’Reilly M, Tremper KK. J Cardiothorac Vasc Anesth. 2008;30:180–186.
    1. Preoperative administration of angiotensin-converting enzyme inhibitors [Article in German] Schirmer U, Schürmann W. Anaesthesist. 2007;56:557–561.
    1. Predictors of hypotension after induction of general anesthesia. Reich DL, Hossain S, Krol M, Baez B, Patel P, Bernstein A, Bodian CA. Anesth Analg. 2005;101:622–628.
    1. Preoperative and intraoperative predictors of cardiac adverse events after general, vascular, and urological surgery. Kheterpal S, O’Reilly M, Englesbe MJ, et al. Anesthesiology. 2009;110:58–66.

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