Format

Send to

Choose Destination
Anesthesiology. 2017 Jan;126(1):16-27.

Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort.

Author information

1
From the London Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada (P.S.R.); Departments of Medicine (B.R., A.P., O.S., E.D., E.P.B.-C., G.H.G., F.K.B., V.T., A.W., F.A.S., Z.P., P.J.D.), Clinical Epidemiology and Biostatistics (B.R., E.D., E.P.B.-C., G.H.G., Y.L.M., A.W., P.J.D.), and Anesthesiology (Y.L.M., J.P., K.E.R.), McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada (E.D., E.P.B.-C., Y.L.M., F.K.B., A.T., M.K., B.D., P.J.D.); Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S.); Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin (R.D.S.); and Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (E.N.S., E.E.M.).

Abstract

BACKGROUND:

The effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before noncardiac surgery is unknown.

METHODS:

In this international prospective cohort study, the authors analyzed data from 14,687 patients (including 4,802 angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users) at least 45 yr old who had in-patient noncardiac surgery from 2007 to 2011. Using multivariable regression models, the authors studied the relationship between withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and a primary composite outcome of all-cause death, stroke, or myocardial injury after noncardiac surgery at 30 days, with intraoperative and postoperative clinically important hypotension as secondary outcomes.

RESULTS:

Compared to patients who continued their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, the 1,245 (26%) angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users who withheld their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in the 24 h before surgery were less likely to suffer the primary composite outcome of all-cause death, stroke, or myocardial injury (150/1,245 [12.0%] vs. 459/3,557 [12.9%]; adjusted relative risk, 0.82; 95% CI, 0.70 to 0.96; P = 0.01) and intraoperative hypotension (adjusted relative risk, 0.80; 95% CI, 0.72 to 0.93; P < 0.001). The risk of postoperative hypotension was similar between the two groups (adjusted relative risk, 0.92; 95% CI, 0.77 to 1.10; P = 0.36). Results were consistent across the range of preoperative blood pressures. The practice of withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers was only modestly correlated with patient characteristics and the type and timing of surgery.

CONCLUSIONS:

Withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. A large randomized trial is needed to confirm this finding. In the interim, clinicians should consider recommending that patients withhold angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 24 h before surgery.

PMID:
27775997
DOI:
10.1097/ALN.0000000000001404
[Indexed for MEDLINE]

Supplemental Content

Full text links

Icon for Silverchair Information Systems
Loading ...
Support Center