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.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:uct/oai:localhost:11427/31682 |
| Date | 23 April 2020 |
| Creators | Hollmann, Caryl |
| Contributors | Biccard, Bruce |
| Publisher | Faculty of Health Sciences, Department of Anaesthesia and Perioperative Medicine |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Master Thesis, Masters, MMed |
| Format | application/pdf |
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