Questions · ACE Inhibitors and ARBs Before Surgery
9 questions, 0 approved. Approve them one at a time — a quiz shows nothing you have not.
Recall — derived from a kept point
In the randomised trial comparing continuing renin-angiotensin system inhibitors up to the day of major noncardiac surgery against stopping them 48 hours beforehand, what happened to the 28-day rate of death and major complications, and what happened to the rate of intraoperative hypotension? Give the approximate numbers for each arm.
Answer: Death and major complications at 28 days were the same in both arms, about 22% each. Intraoperative hypotension differed: it rose from 41% in the discontinuation arm to 54% when the inhibitor was continued to the day of surgery.
The trial shows continuing these drugs buys you more intraoperative hypotension without changing 28-day death or major complications.
Source claim: Continuing renin-angiotensin system inhibitors to the day of surgery gave the same rate of death and major complications at 28 days as stopping them 48 hours before (22% in each arm), but hypotension during surgery rose from 41% to 54%.
Continuation vs Discontinuation of Renin-Angiotensin System Inhibitors Before Major Noncardiac Surgery, JAMA 2024
recall · CA-1 · phrased by llm
A meta-analysis of randomised trials examined withholding versus continuing ACE inhibitors or ARBs before surgery. Withholding them reduces intraoperative hypotension. State the price you pay postoperatively for that benefit, with approximate rates, and say how confident the pooled evidence lets you be.
Answer: Withholding cut intraoperative hypotension from about 48% to 36% and reduced vasopressor use, but the trade-off is more postoperative hypertension, rising from about 20% to 28%. The pooled evidence across those 14 randomised trials was rated very low certainty, so the estimates are weak and should not be treated as settled.
Withholding trades an intraoperative problem for a postoperative one, and at very low certainty the size of both effects is uncertain.
Source claim: Pooling 14 randomised trials, withholding ACE inhibitors or ARBs cut intraoperative hypotension from 48% to 36% and reduced vasopressor use, but raised postoperative hypertension from 20% to 28%, on very low certainty evidence.
Withholding vs. Continuing Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers Before Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, Annals of medicine 2025
recall · CA-2 · phrased by llm
Beyond blocking angiotensin II formation, ACE inhibitors have an effect on sympathetic neurotransmission. Describe that effect and name the circumstance in which it is most pronounced.
Answer: ACE inhibitors attenuate sympathetic neurotransmission, and this attenuation is particularly evident when endogenous renin-angiotensin activity is high.
That is why the hypovolaemic, high-renin patient on an ACE inhibitor loses not just angiotensin support but sympathetic support as well.
Source claim: ACE inhibitors attenuate sympathetic neurotransmission, particularly when endogenous renin-angiotensin activity is high.
Interaction Between the Renin-Angiotensin-Aldosterone and Sympathetic Nervous Systems, Journal of cardiovascular pharmacology 1992
recall · CA-2 · phrased by llm
A prospective cohort of 4,802 patients found that withholding an ACE inhibitor or ARB in the 24 hours before noncardiac surgery was associated with a lower risk of the 30-day composite of death, stroke or myocardial injury. Explain to a junior resident what this study design does NOT establish, and how you would phrase the finding accurately.
Answer: It is a cohort analysis, so the finding is an association between withholding and a lower risk of the 30-day composite of death, stroke or myocardial injury, not a demonstration that withholding causes the improvement. Patients whose drug was withheld may differ systematically from those whose drug was continued, and the design cannot exclude that. The accurate phrasing is that withholding was associated with a lower risk of that composite at 30 days, not that withholding reduces it or should be routinely done.
Say the word association out loud when you quote this cohort, because that is exactly as far as the design will carry you.
Source claim: In a 4,802-patient cohort, withholding an ACE inhibitor or ARB in the 24 hours before noncardiac surgery was associated with a lower risk of the composite of death, stroke or myocardial injury at 30 days.
Withholding Versus Continuing Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers Before Noncardiac Surgery: An Analysis of the Vascular Events in Noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort, Anesthesiology 2017
recall · CA-3 · phrased by llm
In patients whose preoperative NT-proBNP was below ___ pg/mL, stopping RAS inhibitors before surgery raised myocardial injury from 23% to 40% — the harm of stopping is not uniform across risk groups.
Answer: 100
In patients whose preoperative NT-proBNP was below 100 pg/mL, stopping RAS inhibitors before surgery raised myocardial injury from 23% to 40% — the harm of stopping is not uniform across risk groups.
Preoperative N-Terminal Pro-B-Type Natriuretic Peptide and Myocardial Injury After Stopping or Continuing Renin-Angiotensin System Inhibitors in Noncardiac Surgery: A Prespecified Analysis of a Phase 2 Randomised Controlled Multicentre Trial · PMID 38341283
recall · CA-1 · phrased by derived
The point with one number taken out. No model wrote any of this: the stem is the sentence you reviewed, minus a digit, and the paper it came from is named beneath it.
Open prompts
Walk me through your setup for this before we start.
open · CA-1 · phrased by derived
What are you watching on the monitor that would tell you this is going wrong?
open · CA-1 · phrased by derived
What is your first move if it does?
open · CA-1 · phrased by derived
What would you want ready in the room before induction?
open · CA-1 · phrased by derived
Questions only — nothing here asserts anything, which is why a model is allowed to phrase them. Where no model was reachable these are the level defaults.