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Withholding ACE Inhibitors & Effect on CV Outcomes
Anesthesiology; ePub 2016 Oct 24; Roshanov, et al
A lower risk of death and postoperative vascular events was observed after withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers prior to major noncardiac survey, a recent study found. The international cohort study analyzed data from 14,687 patients (≥45 years old; 4,802 angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users) who had in-patient noncardiac surgery from 2007 to 2011. Researchers found:
- 1,245 (25%) angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users who withheld their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in the 24 hours before surgery were less likely to suffer the primary composite outcomes of all-cause death, stroke, or myocardial injury (aRR, 0.82) and intraoperative hypotension (aRR, 0.80), compared to patients who continued.
- Results were consistent across the range of preoperative blood pressures.
Roshanov PS, Rochwerg B, Patel A, et al. Withholding versus continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers before noncardiac surgery: An analysis of the vascular events in noncardiac surgery patient cohort evaluation prospective cohort. [Published online ahead of print October 24, 2016]. Anesthesiology. doi:10.1097/ALN.0000000000001404.
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This is a potentially important study, but should still be viewed as exploratory, since it is a cohort study and subject to confounding variables to which cohort studies can be subject. To address the most likely confounder, that ACEs and ARBs were held more often in patients with lower blood pressure going into surgery, the authors looked at the effect of withholding ACEs and ARBs across a range of systolic BPs and showed that there was no difference in outcomes across the range of BPs. At this point, depending upon a patient’s history of hypertension and their blood pressure going into surgery, one might consider, but by no means is it at this point mandatory to consider, holding ACEs and ARBs on the day of surgery. This is an important study that will require a large randomized study to address further. —Neil Skolnik, MD