ACE inhibitors in cardiac surgery: current studies and controversies

Abstract

Major complications associated with cardiac surgery are still common and carry great prognostic significance. Current medical interventions to prevent these cardiovascular complications include antiplatelet therapy, statins, b-blockers and angiotensinconverting enzyme (ACE) inhibitors. Both experimental studies and clinical trials have shown that ACE inhibitors hold promise as cardiovascular protective agents for cardiac surgery patients. Several lines of evidence support this hypothesis. First, long-term use of ACE inhibitors has been well established to provide cardiovascular protection and reduce ischemic events and complications, independent of their effect on heart function and blood pressure. Second, early ACE inhibitor therapy has been demonstrated to produce remarkable survival and heart function benefits in patients with acute myocardial infarction. Third, ACE blockage can prevent or delay the development or progression of renal disease at all stages, from subclinical microalbuminuria to end-stage renal disease. Nevertheless, perioperative studies of the effects of ACE inhibitors remain few and inconclusive. Results from recent clinical trials and observational studies are conflicting and raise more questions than answers. Further studies, both retrospective and larger-scale prospective studies, are critically needed to examine whether ACE inhibitors reduce mortality and major complications in patients undergoing cardiac surgery.

Thirty‐day mortality risk associated with the postoperative nonresumption of angiotensin‐converting enzyme inhibitors: A retrospective study of the veterans affairs healthcare system

“…Careful attention to the issue of eventual reinstitution of medications for chronic conditions, such as an ACE‐I, is indicated to avoid unnecessary mortality. Because early experience showed that dose titration was a key for successful application of an ACE‐I, practitioners may also need to consider dose modification rather than simply continuation or not restarting . Future research is needed to confirm our results in other healthcare systems and to define mechanisms that link postoperative nonresumption of an ACE‐I to mortality.…”

“…tinuation or not restarting 40. Future research is needed to confirm our results in other healthcare systems and to define mechanisms that link postoperative nonresumption of an ACE-I to mortality.…”

Perioperative use of renin-angiotensin system inhibitors and outcomes in patients undergoing cardiac surgery

“…The propensity score (x-axis) for PreRASi is the probability given baseline variables that any patient in either group would be selected for PreRASi activity of the sympathetic nervous system as well as the trophic effects of angiotensin II. Thus, RASi, by influencing extracellular matrix content, cellular apoptosis, tissue inflammation, and fibrosis, could hypothetically reverse the left ventricularremodeling process, attenuate aortic valve thickening and prevent thrombosis and plaque rapture 6,16,17 .…”

The Effect of Chronic Consumption of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Antagonists on Blood Pressure and Inotrope Consumption After Separation from Cardiopulmonary Bypass

“…Some studies have been reported that consumption of ACEIs and ARAs, until the day of surgery caused hypotension during anesthesia induction (2-4). This point is very important in patients who are a candidate for open-heart surgery with cardiopulmonary bypass (5). It is important to consider that some premedication drugs like benzodiazepines (midazolam), opioids (remifentanil), and anti-convulsion agents (gabapentin and pregabalin) can cause hemodynamic changes during anesthesia induction (6, 7).…”