Effects of the Discontinuation of Angiotensin-Converting Enzyme Inhibitors 12 and 24 Hours Before Open-Heart Surgery on Hemodynamics During and After Surgery

Document Type : Original Article


1 Bou Ali Sina Hospital, Qazvin University of Medical sciences, Qazvin, IR Iran.

2 Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, IR Iran.


Background: Preoperative use of angiotensin-converting enzyme inhibitors (ACEIs) is an independent predictor of the need for inotropic support postoperatively and hypotension during surgery; consequently, some surgeons suggest that ACEIs be discontinued prior to coronary artery bypass graft surgery (CABG). However, the optimal time of ACEI discontinuation before CABG remains controversial. In this study, we compared the effects of ACEI discontinuation 12 and 24 hours before open-heart surgery on the hemodynamic status of patients during surgery.
Methods: This randomized controlled trial was conducted on patients undergoing elective CABG. The patients were randomly divided into 2 groups: in the first group, ACEIs were discontinued 12 hours before CABG and in the second group, ACEIs were discontinued 24 hours before CABG. Hemodynamic evaluations including blood pressure (systolic, diastolic, and mean arterial pressures), the heart rate, and the hemoglobin level were performed.
Results: The trends of changes in systolic blood pressure (P = 0.41), diastolic blood pressure (P = 0.360), the heart rate (P = 0.11), and the hemoglobin level (P = 0.92) were not significantly different between the 2 groups over time. The mean arterial pressure was significantly different between the groups over time (P = 0.038). Likewise, the mean arterial pressure in the 24-hour group was significantly higher than that of the other group until the time of sternotomy, after which time the mean arterial pressure in the 12-hour group was significantly higher.
Conclusions: ACEI discontinuation before CABG had some effects on the hemodynamics of our patients during anesthetic induction, including the prevention of hypotension during surgery; nonetheless, our data did not show the optimal time to stop ACEIs prior to CABG. (Iranian Heart Journal 2020; 21(2): 27-33)


1. Drenger B1, Fontes ML, Miao Y, Mathew JP, Gozal Y, Aronson S, et al. 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. Circulation. 2012 Jul 17;126(3):261-9. doi: 10.1161/CIRCULATIONAHA.111.059527. Epub 2012 Jun 19.
2. Miceli A, Capoun R, Fino C, Narayan P, Bryan AJ, Angelini GD, et al. Effects of angiotensin-converting enzyme inhibitor therapy on clinical outcome in patients undergoing coronary artery bypass grafting. J Am Coll Cardiol. 2009 Nov 3;54(19):1778-84. doi: 10.1016/j.jacc.2009.07.008. Epub 2009 Aug 13.
3. Lee YK, Na SW, Kwak YL, Nam SB. Effect of pre-operative angiotensin-converting enzyme inhibitors on haemodynamic parameters and vasoconstrictor requirements in patients undergoing off-pump coronary artery bypass surgery. J Int Med Res. 2005 Nov-Dec;33(6):693-702.
4. Radaelli G, Bodanese LC, Guaragna JC, Borges AP, Goldani MA, Petracco JB, et al.
The use of inhibitors of angiotensin-converting enzyme and its relation to events in the postoperative period of CABG. Rev Bras Cir Cardiovasc. 2011 Jul-Sep;26(3):373-9.
5. Arora P, Rajagopalam S, Ranjan R, Kolli H, Singh M, Venuto R, et al. Pre-operative use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers is associated with increased risk for acute kidney injury after cardiovascular surgery. Clin J Am Soc Nephrol. 2008;3(5):1266-73.
6. Pass SE, Simpson RW. Discontinuation and reinstitution of medications during the perioperative period. Am J Health Syst Pharm. 2004;1;61(9):899-912.
7. Sun JZ, Cao LH, Liu H. ACE inhibitors in cardiac surgery: current studies and controversies. Hypertens Res. 2011 Jan; 34(1):15-22.
8. Ebadi A, Soltanzadeh M, Nesioonpour S, Akhondzadeh R, Dehghani Firoozabadi M, Attariyan M. Effects of Angiotensin Converting Enzyme Inhibitors Before, During and After Coronary Artery Bypass Graft Surgery on Hemodynamic Responses and Vasoactive Drugs Requirement. Anesthesiology and Pain Medicine. 2013; 4(3). e16510.
9. Düsing R. Pharmacological interventions into the renin-angiotensin system with ACE inhibitors and angiotensin II receptor antagonists: effects beyond blood pressure lowering. Ther Adv Cardiovasc Dis. 2016; 10(3): 151-61.
10. Deakin CD, Dalrymple-Hay MJ, Jones P, Monro JL. Effects of angiotensin converting enzyme inhibition on systemic vascular resistance and vasoconstrictor requirements during hypothermic cardiopulmonary bypass. Eur J Cardiothorac Surg. 1998;13(5):546-50.
11. White CM, Kluger J, Lertsburapa K, Faheem O, Coleman CI. Effect of pre-operative angiotensin converting enzyme inhibitor or angiotensin receptor blocker use on the frequency of atrial fibrillation after cardiac surgery: a cohort study from the atrial fibrillation suppression trials II and III. Eur J Cardiothorac Surg. 2007;31(5):817–20.
12. Drenger B, Fontes ML, Miao Y; et al. 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. Circulation. 2012; 17;126(3):261-9.
13. Devbhandari MP, Balasubramanian SK, Codispoti M, Nzewi OC, Prasad SU. Preoperative angiotensin-converting enzyme inhibition can cause severe post CPB vasodilation – current UK opinion. Asian Cardiovasc Thorac Ann. 2004;12:346-349.
14. Bertrand M, Godet G, Meersschaert K, Brun L, Salcedo E, Coriat P. Should the angiotensin II antagonists be discontinued before surgery? Anesth Analg 2001;92:26-30.