The edition · Internal Medicine
Withholding the ACE inhibitor before surgery changed nothing across 638 patients
A randomised trial finds no difference in cardiovascular events, intraoperative hypotension or acute kidney injury whether angiotensin-axis blockers are continued or held for 24 hours before elective non-cardiac surgery. A new tobacco treatment guideline puts varenicline and combination nicotine replacement ahead of single-agent therapy, and half of hospitalists think asymptomatic inpatient hypertension should be left alone.
The edition in brief
A single-centre randomised trial addressed a question asked at every preoperative clinic: should a patient's angiotensin-converting enzyme inhibitor or angiotensin receptor blocker be held before elective non-cardiac surgery? Of 667 patients randomised, 638 were analysed. Major adverse cardiovascular events at five days occurred in 2.8% of those continuing and 2.9% of those withholding. Intraoperative hypotension was common in both arms at 63.5% and 60.7%, and acute kidney injury occurred in 7.4% and 4.8%, neither difference statistically significant. The population was low cardiac risk and the trial was single blind at one hospital. The 2026 US Department of Veterans Affairs and Department of Defense tobacco use guideline makes 32 recommendations. The strong ones are clear: motivational interviewing to engage patients, US Food and Drug Administration-approved pharmacotherapy, varenicline in preference to other monotherapy, and combination nicotine replacement such as patch plus lozenge in preference to a single agent. Extending bupropion sustained release beyond 12 weeks is a weak recommendation, as is offering nicotine replacement or varenicline to patients not planning to quit within 30 days. A survey of 166 hospitalists across five institutions found 27% considered treating asymptomatic elevated inpatient blood pressure important and 47% disagreed. The median threshold for intensifying treatment was a systolic of 170 to 179 mmHg, and respondents agreed that treatment is driven by nurses calling physicians rather than by a clinical decision. A retrospective cohort reports lower mortality with calcium channel blockers in heart failure with advanced chronic kidney disease. It should be read with care.
New tobacco guideline: varenicline first, and combination nicotine replacement over a single agent
Prescribe varenicline or combination nicotine replacement rather than a single patch, and offer it before the patient has committed to a quit date.
Half of hospitalists think asymptomatic inpatient hypertension should be left alone — and say the nurse's call is what drives treatment
Write the blood pressure you want to be called about into the admission orders, because that number — not a guideline — is what determines whether the patient gets treated.
Calcium channel blockers looked protective in heart failure with advanced kidney disease — read that carefully
Treat this as evidence that calcium channel blockers are not harmful for blood pressure control in this group, not as a reason to prescribe them for survival.
The admission drug list is a set of decisions made by other people, for reasons no longer written down
Read the admission medication list as a set of past decisions to be re-examined, not a status to be transcribed.
Holding angiotensin-axis blockers before elective surgery gave no benefit in a randomised trial
Stop routinely holding angiotensin-axis blockers before elective low-risk non-cardiac surgery — and if you do hold one, document when it restarts.
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