The Morning Pill to Leave in the Bottle Before Surgery

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Key Takeaway

In a double-blind clinical trial involving 2,012 older adults taking an ACE inhibitor or ARB, withholding solely the morning dose prior to noncardiac surgery reduced the incidence of hazardous intraoperative hypotension from 45.5% to 31.2%. Significantly fewer patients required vasopressors to restore vascular tone. No significant differences were observed between groups regarding 30-day complications or overall mortality.

The Medication That Arrives in the Operating Room Before the Patient

Consider a 70-year-old patient awaiting gallbladder surgery in the quiet hours of early morning. They have adhered meticulously to every preoperative instruction: nothing by mouth after midnight, save for a single sip of water to swallow their daily blood pressure pill, just as they have done every morning for a decade. Two hours later, the anesthesiologist induces general anesthesia. Within minutes, the patient’s arterial pressure plummets. Monitors alarm across the operating suite, and the surgical team immediately reaches for a vasopressor to constrict the dilated vasculature and rescue perfusion.

This clinical scenario unfolds daily in surgical suites worldwide. Ever since angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) became cornerstones of cardiovascular medicine, perioperative physicians have debated whether that morning dose should be administered or withheld. While these pharmacotherapies carry established long-term benefits for cardiac performance, renal preservation, and blood pressure control, they…