Article Impact Level: HIGH Data Quality: STRONG Summary of European Heart Journal, ehad716. https://doi.org/10.1093/eurheartj/ehad716 Dr. Gareth L Ackland et al.
Points
- Perioperative myocardial injury is a concern in patients receiving renin-angiotensin system (RAS) inhibitors during non-cardiac surgery.
- This study aimed to determine whether discontinuing RAS inhibitors before surgery reduces myocardial injury and assesses the occurrence of adverse hemodynamic events.
- The trial included 262 participants aged 60 years or older randomly assigned to discontinue or continue their RAS inhibitors.
- Discontinuing RAS inhibitors did not reduce myocardial injury compared to continuing them, with similar rates of hypotension in both groups.
- However, discontinuation of RAS inhibitors increased the risk of clinically significant acute hypertension, suggesting routine discontinuation may not be beneficial, and further research is needed.
Summary
Perioperative myocardial injury is a concern in patients undergoing non-cardiac surgery, particularly those receiving renin-angiotensin system (RAS) inhibitors. The optimal approach to managing RAS inhibitors perioperatively, either discontinuing them to minimize hypotension or continuing them to avoid hypertension, remains uncertain. This study aimed to investigate whether stopping RAS inhibitors before surgery reduces perioperative myocardial injury and to assess the occurrence of adverse hemodynamic events.
A randomized controlled trial was conducted in six UK centers from July 2017 to October 2021. Patients aged 60 years or older undergoing elective non-cardiac surgery were randomly assigned to either discontinue or continue their RAS inhibitors prescribed for existing medical conditions. The duration of withholding RAS inhibitors varied based on their pharmacokinetic profile. The primary outcome was myocardial injury, defined as elevated plasma high-sensitivity troponin-T (hs-TnT) levels within 48 hours after surgery. Adverse hemodynamic events, including acute hypertension and hypotension requiring vasoactive therapy, were also assessed.
A total of 262 participants were included, with 130 in the discontinuation group and 132 in the continuation group. Myocardial injury occurred in 48.3% of patients who discontinued RAS inhibitors compared to 41.3% of patients who continued them. The odds ratio for myocardial injury in the continuation group was 0.77 (95% confidence interval 0.45-1.31). Hypertensive adverse events were more frequent in the discontinuation group (12.4%) compared to the continuation group (5.3%), with an odds ratio of 0.4 (95% CI 0.16-1.00). Rates of hypotension were similar between the two groups.
Discontinuing RAS inhibitors before non-cardiac surgery did not reduce the incidence of peri-operative myocardial injury and may increase the risk of clinically significant acute hypertension. These findings suggest that routine discontinuation of RAS inhibitors may not be beneficial and should be further investigated in future studies.
Link to the article: https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad716/7339818
References Ackland, G. L., Patel, A., Abbott, T. E. F., Begum, S., Dias, P., Crane, D. R., Somanath, S., Middleditch, A., Cleland, S., Gutierrez Del Arroyo, A., Brealey, D., Pearse, R. M., the Stopping Perioperative ACE-inhibitors or angiotensin-II receptor blockers (SPACE) trial investigators, Ackland, G., Martin, T., Fernandez, M., Seidu, F., Pakats, M.-L., Mahr, O., … Harris, S. (2023). Discontinuation vs. continuation of renin–angiotensin system inhibition before non-cardiac surgery: The SPACE trial . European Heart Journal, ehad716. https://doi.org/10.1093/eurheartj/ehad716
