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A systematic review of outcomes associated with withholding or continuing angiotensinconverting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) prior to noncardiac surgery
Introduction The global rate of major noncardiac surgical procedures is increasing annually, and of those patients presenting for surgery increasing numbers are taking either an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin receptor blocker(ARB). The current recommendations w...
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| Format: | Thesis |
| Language: | English |
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Department of Anaesthesia and Perioperative Medicine
2020
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| Summary: | Introduction
The global rate of major noncardiac surgical procedures is increasing annually, and of those patients presenting for surgery increasing numbers are taking either an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin receptor blocker(ARB). The current recommendations whether to continue or withhold ACE-I and ARB in the perioperative period are conflicting. Previous metaanalyses have linked preoperative ACE-I /ARB therapy to the increased incidence of post induction hypotension, however have failed to correlate this with adverse patient outcomes. The aim of this meta-analysis was to determine whether continuation or withholding ACE-I or ARB therapy in the perioperative period is associated with mortality and major morbidity.
Methods
This meta-analysis was prospectively registered on PROSPERO (CRD42017055291). A comprehensive search of MEDLINE (PubMed), CINAHL (EBSCO host), ProQuest, Cochrane database, Scopus and Web of Science was conducted on 06 December 2016. We included adult patients >18years, on chronic ACE-I or ARB therapy who underwent noncardiac surgery, where ACE-I or ARB was either withheld or continued on the morning of surgery. Primary outcomes included all-cause mortality and major cardiac events (MACE). Secondary outcomes included the risk of congestive heart failure (CHF), acute kidney injury, stroke, intra/postoperative hypotension and the length of hospital stay (LOS).
Results
Following abstract review, the full text of 25 studies were retrieved, of which nine fulfilled the inclusion criteria; five were randomized control trials (RCTs) and four cohort studies. These studies included a total of 6022 patients on chronic ACE-I/ARB therapy prior to noncardiac surgery. 1816 patients withheld treatment the morning of surgery and 4206 continued their ACE-I/ARB. Preoperative demographics were similar between the two groups. Withholding ACE-I/ARB therapy was not associated with a difference in mortality (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.62-1.52; I2 =0%) or MACE (OR 1.12; 95% CI 0.82-1.52; I2 =0%). Withholding therapy was however associated with significantly less intra-operative hypotension (OR 0.63 95% CI 0.47;0.85, I 2 =71%). No effect estimate could be pooled concerning length of hospital stay and CHF.
Conclusions
This meta-analysis did not demonstrate an association between perioperative administration of ACEI/ARB, and mortality or MACE. It did however confirm the current observation that perioperative continuation of ACE-I/ARBs is associated with an increased incidence of intra-operative hypotension. A large randomized control trial is necessary to determine the appropriate perioperative management of ACE-I and ARBs. |
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