Withholding ACE inhibitors and ARBs before surgery brought no benefit in a randomised trial

The edition in brief

In the PAAB trial, 638 patients on ACE inhibitors or angiotensin receptor blockers having elective non-cardiac surgery at one Australian hospital were randomised to continue or withhold them for 24 hours; major cardiac events at five days were 2.8% v 2.9%, intraoperative hypotension 63.5% v 60.7% and acute kidney injury 7.4% v 4.8%, none significantly different. Patients were at low cardiac risk and the trial was not powered for rare events. A Korean study of 9.8 million results from 101,148 outpatients found that fasting under eight hours raised glucose, triglycerides, GGT and lipase beyond acceptable analytical error, but nothing differed meaningfully between 8–12 hours and longer fasts. A meta-analysis of 22 studies found non-thyroidal illness syndrome and isolated low T3 were each associated with about three times the odds of death in acute illness, a prognostic marker rather than a target. A survey of 166 hospitalists found only 27% thought asymptomatic raised inpatient blood pressure important to treat, with a median treatment threshold of 170–179 mm Hg systolic. Bright light therapy for delirium prevention had an uncertain effect (RR 0.64, 95% CI 0.38 to 1.07) on very low certainty evidence. The pearl covers multicomponent delirium prevention.