Every morning, millions of older people with high blood pressure swallow the pill that has steadied them for years, and then face the uncertain hours of surgery without clear guidance on whether to take it. In a randomized trial published in The BMJ, researchers in China followed 2,012 adults aged 60 to 80 undergoing non-cardiac surgery across five hospitals, and found that quietly omitting the morning dose of an ACE inhibitor or angiotensin receptor blocker lowered the chance of dangerous dips in blood pressure during the operation. The benefit was real but narrow, reaching the operating room
Skipping Morning Blood Pressure Pill Before Surgery Cuts Risk of Dangerous Low Pressure in Older Adults
Skip the morning dose on the day of surgery
Mark
So the headline is that skipping one pill changes what happens on the operating table?
Mimi
Yes. Hypotension needing treatment occurred in 31.2% of patients who got a placebo, against 45.5% of those who took their usual ACE inhibitor or ARB. That's a big difference for a one-dose change.
Mark
Why does low pressure during surgery matter so much?
Mimi
In older adults it can lead to acute kidney injury, heart attack and death. Anaesthetists have to treat it, and vasopressor use was also lower in the skipped-dose group, 28.5% versus 41.1%.
Luke
Before we get carried away: did fewer people actually come to harm? The report says postoperative hypotension, 30-day complications and death didn't differ significantly.
Mimi
Right. The confirmed benefit is during the operation. Whether skipping the dose improves outcomes afterwards, this trial didn't show.
Mark
Is that a weakness of the study?
Luke
It's a limit on what can be claimed. Follow-up was only 30 days, and the authors themselves say longer-term outcomes need study. The phrase 'high certainty' applies to the intraoperative finding.
Mimi
And the design is strong. Identical placebos masked both patients and anaesthetists, and participants had been on these drugs for about 10 years on average.
Mark
Does this apply to everyone having surgery?
Luke
Not necessarily. Participants were Chinese patients aged 60 to 80 at five hospitals, having moderate-length non-cardiac surgery. The authors say it may not hold for very high-risk operations or other countries.
Mimi
Which is why they say it should inform guidelines, not that it settles them.
Il Polso
- Blood pressure can fall dangerously low during surgery in older patients, raising the risk of kidney injury, heart attack and death.
- Clinicians have long debated whether to stop daily ACE inhibitors and ARBs before operations, with earlier studies giving conflicting answers.
- A 2,012-patient randomized trial used identical placebos so neither patients nor anaesthetists knew who had taken the real drug.
- Intraoperative hypotension fell from 45.5% to 31.2% and vasopressor use dropped from 41.1% to 28.5% among those skipping the dose.
- Postoperative hypotension, 30-day complications and deaths showed no significant difference, leaving the broader benefit unproven.
- Researchers expect the findings to shape international guidelines, pending larger and longer studies.
Every morning, millions of older people with high blood pressure swallow the pill that has steadied them for years, and then face the uncertain hours of surgery without clear guidance on whether to take it. In a randomized trial published in The BMJ, researchers in China followed 2,012 adults aged 60 to 80 undergoing non-cardiac surgery across five hospitals, and found that quietly omitting the morning dose of an ACE inhibitor or angiotensin receptor blocker lowered the chance of dangerous dips in blood pressure during the operation. The benefit was real but narrow, reaching the operating room but not the recovery ward, and the question of how far it travels beyond these patients and this 30-day horizon remains open.
A patient in their late sixties, on blood pressure tablets for about a decade, is facing an operation and asks what to do with the morning pill. For years the answer has been unclear. A new trial published today in The BMJ offers a simple suggestion: skip it.
The study followed 2,012 people aged 60 to 80 with high blood pressure who were undergoing non-cardiac surgery under general anaesthesia at five large Chinese hospitals. Older adults often drop sharply in blood pressure during surgery, which can lead to kidney injury, heart attack and death, and roughly a third of operations worldwide involve patients over 60. Earlier research had been inconclusive, and guidelines offered only weak advice.
Participants were randomly assigned to take their usual ACE inhibitor or ARB, or an identical placebo, so no one knew which they had. Among those who skipped the real dose, 31.2% experienced treatment-requiring low blood pressure during surgery, compared with 45.5% of those who took it. Fewer needed a vasopressor drug too. But the advantage did not extend past the operation: complications within 30 days, postoperative low blood pressure and death were no different between groups.
The authors acknowledge limits, including the trial's focus on Chinese patients, moderate-length surgeries and a short follow-up. They still argue the evidence is strong enough to recommend omitting the morning dose in this population, and they expect it to inform future international guidelines once wider, longer studies confirm how far it applies.
A patient in their late sixties, on blood pressure tablets for about a decade, is told what to do on the morning of an operation. For years the answer has been unclear. A trial published today in The BMJ suggests a simple one: skip that morning pill.
The study tested two widely prescribed drug classes, ACE inhibitors and angiotensin receptor blockers (ARBs), in 2,012 people aged 60 to 80 who had high blood pressure. The average age was 69, and 54% of participants were men. All were having non-cardiac surgery under general anaesthesia at five large Chinese hospitals between November 2020 and December 2023.
The question matters because roughly one third of surgeries worldwide involve patients aged 60 or older, and many of them take daily blood pressure medication. Older adults are prone to hypotension during surgery, which can lead to acute kidney injury, heart attack and death. Earlier research gave mixed answers. Some studies found that stopping these drugs two to three days before surgery lowered the risk of hypotension, while others found no difference. Clinical guidelines offer only weak recommendations.
In the trial, patients were randomly assigned to one of two groups. In the first, 1,004 took their usual tablet on the morning of surgery. In the second, 1,008 received an identical placebo, so neither patients nor anaesthetists knew who had taken the real drug. The researchers counted episodes of low blood pressure during the operation that required treatment, defined as a mean reading below 65 mmHg or a drop of at least 30% from the pre-operative level.
The gap was clear. Among those given the placebo, 314 of 1,008 patients (31.2%) had such an episode. Among those who took their medication as normal, the figure was 457 of 1,004 (45.5%). Time spent in hypotension was also shorter in the placebo group, by a mean of 1.3 minutes. The need for a vasopressor, a drug used to raise dangerously low blood pressure, was lower too: 28.5% versus 41.1%.
The benefit did not carry through to the other measures. Postoperative hypotension, complications within 30 days and death did not differ significantly between the groups.
The authors are open about the limits. They enrolled older Chinese patients undergoing surgery of moderate length, so the results may not apply to very high-risk operations or to populations in other countries. Patients were followed for only 30 days, and longer-term outcomes need further study. They also point to strengths: participants had taken these drugs for an average of 10 years, and the identical placebos masked patients and anaesthetists, removing a source of bias that may have affected earlier trials.
The researchers say the work "provides high certainty evidence supporting omission of the morning dose in this population." They argue that stopping ACE inhibitors or ARBs before non-cardiac surgery should be considered whenever hypotension during the operation is a concern, supporting a simple instruction to patients to skip the morning dose on the day of surgery. They expect the findings to inform future international guidelines, though wider and longer studies will show how far the result extends.
Citazioni salienti
Provides high certainty evidence supporting omission of the morning dose in this population.— Trial researchers, The BMJ
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