Cardiac Arrest during Total Hip Arthroplasty in a Patient on an Angiotensin Receptor Antagonist


Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor antagonists (ARA) are effective and well-tolerated first-line drugs in the therapy of hypertension and, therefore, are frequently encountered in the perioperative setting. Hemodynamic compensation for volume depletion seen in the perioperative period is normally mediated by the renin–angiotensin system, which is blocked by ACEI/ARA. These drugs may contribute to severe hypotension during anesthesia induction and may have contributed to the cardiac arrest seen in this patient. Additional factors such as increased intra-abdominal pressures and respiratory obstructive episodes leading to diminished venous return, as well diuretic use and the fasting state, common in the perioperative orthopedic patient, are likely to have contributed as well. Medication use may be an easily modifiable risk factor for severe hypotension and possible cardiac arrest in the perioperative setting.

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  1. 1.

    Arora P, Rajagopalam S, Ranjan R, Kolli H, Singh M, Venuto R, Lohr J. Preoperative use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers is associated with increased risk for acute kidney injury after cardiovascular surgery. Clin J Am Soc Nephrol. 2008;5:1266–1273.

    Article  Google Scholar 

  2. 2.

    Barreras A, Gurk-Turner C. Angiotensin II receptor blockers. Proc (Bayl Univ Med Cent). 2003;1:123–126.

    Google Scholar 

  3. 3.

    Brabant SM, Bertrand M, Eyraud D, Darmon PL, Coriat P. The hemodynamic effects of anesthetic induction in vascular surgical patients chronically treated with angiotensin II receptor antagonists. Anesth Analg. 1999;6:1388–1392.

    Google Scholar 

  4. 4.

    Brabant SM, Eyraud D, Bertrand M, Coriat P. Refractory hypotension after induction of anesthesia in a patient chronically treated with angiotensin receptor antagonists. Anesth Analg. 1999;4:887–888.

    Google Scholar 

  5. 5.

    Butterworth J, Furberg CD. Improving cardiac outcomes after noncardiac surgery. Anesth Analg. 2003;3:613–615.

    Article  Google Scholar 

  6. 6.

    Cittanova ML, Zubicki A, Savu C, Montalvan C, Nefaa N, Zaier K, Riou B, Coriat P. The chronic inhibition of angiotensin-converting enzyme impairs postoperative renal function. Anesth Analg. 2001;5:1111–1115.

    Article  Google Scholar 

  7. 7.

    Colson P, Ryckwaert F, Coriat P. Renin angiotensin system antagonists and anesthesia. Anesth Analg. 1999;5:1143–1155.

    Article  Google Scholar 

  8. 8.

    Comfere T, Sprung J, Kumar MM, Draper M, Wilson DP, Williams BA, Danielson DR, Liedl L, Warner DO. Angiotensin system inhibitors in a general surgical population. Anesth Analg. 2005;3:636–44, table of contents.

    Article  Google Scholar 

  9. 9.

    Cozanitis DA. The importance of interrupting angiotensin converting enzyme inhibitor treatment before spinal anaesthesia--a controlled case report. Anaesthesiol Reanim. 2004;1:16–18.

    Google Scholar 

  10. 10.

    Eyraud D, Mouren S, Teugels K, Bertrand M, Coriat P. Treating anesthesia-induced hypotension by angiotensin II in patients chronically treated with angiotensin-converting enzyme inhibitors. Anesth Analg. 1998;2:259–263.

    Google Scholar 

  11. 11.

    Hartmann B, Junger A, Klasen J, Benson M, Jost A, Banzhaf A, Hempelmann G. The incidence and risk factors for hypotension after spinal anesthesia induction: An analysis with automated data collection. Anesth Analg. 2002;6:1521–9, table of contents.

    Google Scholar 

  12. 12.

    Kashihara K. Roles of arterial baroreceptor reflex during bezold-jarisch reflex. Curr Cardiol Rev. 2009;4:263–267.

    Article  Google Scholar 

  13. 13.

    Kheterpal S, Khodaparast O, Shanks A, O’Reilly M, Tremper KK. Chronic angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy combined with diuretic therapy is associated with increased episodes of hypotension in noncardiac surgery. J Cardiothorac Vasc Anesth. 2008;2:180–186.

    Article  Google Scholar 

  14. 14.

    Larochelle P, Flack JM, Marbury TC, Sareli P, Krieger EM, Reeves RA. Effects and tolerability of irbesartan versus enalapril in patients with severe hypertension. irbesartan multicenter investigators. Am J Cardiol. 1997;12:1613–1615.

    Article  Google Scholar 

  15. 15.

    Liu SS, Della Valle AG, Besculides MC, Gaber LK, Memtsoudis SG. Trends in mortality, complications, and demographics for primary hip arthroplasty in the united states. Int Orthop. 2009;3:643–651.

    Article  Google Scholar 

  16. 16.

    Memtsoudis SG, Della Valle AG, Besculides MC, Gaber L, Laskin R. Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty. J Arthroplasty. 2009;4:518–527.

    Article  Google Scholar 

  17. 17.

    Moser M. Angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists and calcium channel blocking agents: A review of potential benefits and possible adverse reactions. J Am Coll Cardiol. 1997;7:1414–1421.

    Article  Google Scholar 

  18. 18.

    Railton CJ, Wolpin J, Lam-McCulloch J, Belo SE. Renin-angiotensin blockade is associated with increased mortality after vascular surgery. Can J Anaesth. 2010;8:736–744.

    Google Scholar 

  19. 19.

    Wijeysundera DN, Beattie WS. Calcium channel blockers for reducing cardiac morbidity after noncardiac surgery: A meta-analysis. Anesth Analg. 2003;3:634–641.

    Article  Google Scholar 

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Correspondence to Susan M. Goodman MD.

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CME questions for “Cardiac arrest during total hip arthroplasty in a patient on an angiotensin receptor antagonist”

1. What factors may complicate stopping ACE inhibitors perioperatively:

a. Intra and postoperative hypertension.

b. Postoperative hypotension

c. Difficulty in converting to other antihypertensive agents effectively and timely.

d. a & c

e. all of the above

2. Which factor can contribute to postoperative hypotension in patients on ACE inhibitors:

a. Postoperative pain

b. Intra and postoperative anemia and blood loss

c. perioperative anxiety

d. Prolonged NPO status

e. b & d

f. all of the above

3. Intra and postoperative hypertension increases the risk of:

a. surgical blood loss

b. cardiac arrhythmias

c. stroke

d. all of the above

4. ACEI inhibit the synthesis of angiotensin II. The effect of AII includes:

a. vasodilation

b. vasoconstriction

c. vasopressor potentiation

d. a & c

e. b & c

5. Significant hypotension at the time of anesthesia induction is most common in patients treated with:

a. calcium channel blocking agents

b. beta blocking agents


d. Angiotensin receptor antagonists

6. Acute kidney injury is a common complication of cardiac surgery. Risk factors include:

a. increased age

b. Diabetes

c. neurologic disease

d. ACEI/ARA therapy

e. b & c

f. all of the above

7. Medications which should be continued and taken on the morning of surgery in a patient with hypertension, angina, and normal cardiac function:

a. metoprolol

b. furosemide

c. lisinopril

d. Plavix

8. The Betzold –Jarisch reflex, mediated by cardiopulmonary vagal fibers, results in paradoxical bradycardia and precipitous hypotension. This is accentuated with:

a. prolonged standing

b. hypovolemia

c. anemia

d. all of the above

9. Beta blockers have a protective effect on patients in the intra and postoperative period, decreasing the incidence of which of the following:

a. myocardial infarction

b. stroke

c. hypotension

d. wound dehiscence

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Discuss and be able to use appropriate chemical messenger systems, such as the Renin Activating System, in maintenance of hemodynamic stability in the setting of regional anesthesia and orthopaedic surgery.

1 2 3 4 5 6 7

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Describe antihypertensive agents, such as Angiotensin converting enzyme inhibitors (ACEI) and Angiotensin receptor antagonists (ARA), and their interactions with the Renin Activating System blockade, and how they are less likely to produce profound hypotension for patients in the orthopaedic setting.

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Discuss factors, such as dehydration and anemia, which may magnify the potential for hypotension in orthopaedic patients undergoing regional anesthesia.

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□ □ □ □ □ □ □

Describe the mechanism by which an increase in intra-abdominal and intra-thoracic pressure can diminish venous return and further increase the importance of Renin Activating System mediated compensation.

1 2 3 4 5 6 7

□ □ □ □ □ □ □

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Goodman, S.M., Krauser, D., Mackenzie, C.R. et al. Cardiac Arrest during Total Hip Arthroplasty in a Patient on an Angiotensin Receptor Antagonist. HSS Jrnl 8, 175–183 (2012).

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  • cardiac arrest
  • perioperative antihypertensive therapy
  • Angiotensin converting enzyme inhibitors
  • Bezold –Jarisch reflex
  • intra-operative hypotension
  • renin angiotensin system (RAS)