Thirty-day mortality risk associated with the postoperative nonresumption of angiotensin-converting enzyme inhibitors: a retrospective study of the Veterans Affairs Healthcare System

J Hosp Med. 2014 May;9(5):289-96. doi: 10.1002/jhm.2182.


Background: Angiotensin-converting enzyme inhibitors (ACE-Is) are a widely used class of cardiovascular medication. However, limited data exist on the risks of postoperative nonresumption of an ACE-I.

Objective: To evaluate the factors and 30-day mortality risks associated with the postoperative nonresumption of an ACE-I.

Design: A retrospective cohort study.

Setting: Veterans Affairs (VA) Healthcare System.

Patients: A total of 294,505 admissions in 240,978 patients with multiple preoperative prescription refills (>3) for an ACE-I who underwent inpatient surgery from calendar years 1999 to 2012.

Intervention: None.

Measurements: We classified surgical admissions based upon the timing of postoperative resumption of an ACE-I prescription from the day of surgery through postoperative days 0 to 14 and 15 to 30, and collected 30-day mortality data. We evaluated the relationship between 30-day mortality and the nonresumption of an ACE-I from postoperative day 0 to 14 using proportional hazard regression models, adjusting for patient- and hospital-level risk factors. Sensitivity analyses were conducted using more homogeneous subpopulations and propensity score models.

Results: Twenty-five percent of our cohort did not resume an ACE-I during the 14 days following surgery. Nonresumption of an ACE-I within postoperative day 0 to 14 was independently associated with increased 30-day mortality (hazard ratio: 3.44; 95% confidence interval: 3.30-3.60; P < 0.001) compared to the restart group. Sensitivity analyses maintained this relationship.

Conclusions: Nonresumption of an ACE-I is common after major inpatient surgery in the large VA Health Care System. Restarting of an ACE-I within postoperative day 0 to 14 is, however, associated with decreased 30-day mortality. Careful attention to the issue of timely reinstitution of chronic medications such as an ACE-I is indicated.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Angiotensin-Converting Enzyme Inhibitors / administration & dosage
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
  • Cardiovascular Diseases / drug therapy
  • Diabetes Mellitus / drug therapy
  • Female
  • Humans
  • Male
  • Middle Aged
  • Perioperative Care / methods*
  • Postoperative Complications / drug therapy
  • Postoperative Complications / mortality*
  • Proportional Hazards Models
  • Retrospective Studies
  • Risk Factors
  • San Francisco
  • Time Factors
  • United States
  • Veterans / statistics & numerical data*


  • Angiotensin-Converting Enzyme Inhibitors