Prescribing Safety Assessment (PSA) Practice Exam

When should ACE inhibitors be discontinued before surgery?

1. One week prior

2. The day before

3. The day of surgery

4. They should not be stopped

The correct answer is: The day of surgery

Discontinuing ACE inhibitors on the day of surgery is supported by the consideration of their pharmacological effects. ACE inhibitors, such as ramipril or lisinopril, act to lower blood pressure by inhibiting the conversion of angiotensin I to angiotensin II. While they are generally safe to continue in many surgical situations, particularly in patients with controlled hypertension, they can lead to hypotension, especially if combined with anesthetic agents and intravenous fluids during surgery. Stopping them on the day of surgery allows for the minimization of the risk of intraoperative hypotension while also ensuring that the patient does not experience rebound hypertension that can occur if they are withdrawn abruptly. This approach helps in managing the patient's hemodynamic stability during the procedure without compromising their cardiovascular status immediately before surgery. In some cases, guideline recommendations may vary, but the preference for stopping on the day of surgery is often due to the need for balance between maintaining therapeutic effect and avoiding potential complications. Other options, such as stopping them a week prior or even the day before, may unnecessarily increase the risk of cardiovascular instability, making them less favorable in this context.