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

Ding, Qian; Zhang, Zugui; Liu, Hong; Nie, Huang; Berguson, Mark; Goldhammer, Jordan E.; Young, Nilas; Boyd, Douglas; Morris, Rohinton J.; Sun, Jianyong

doi:10.1038/s41467-019-11678-9

Cited by 17 publications

(6 citation statements)

References 44 publications

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“…This protective effect is in line with our previously findings in the entire patient sample, without controlling for whether the patient has HF or not. 32 Comparing the results of the survival analyses between these two studies, we found smaller hazard ratios for the protective effect of PreRASi on postoperative mortality. This implies that PreRASi exerts more significant protection against mortality in patients with HF, which was further supported by the findings that neither PreRASi nor PostRASi provided protection against 6-year mortality in patients without HF history (Figure S8, http://links.lww.com/SLA/D700, S9, http://links.lww.com/SLA/D701).…”

Section: Discussionmentioning

confidence: 76%

Perioperative Renin–Angiotensin System Inhibitors Improve Major Outcomes of Heart Failure Patients Undergoing Cardiac Surgery

et al. 2022

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The aim of this study was to study the association of perioperative administration of renin angiotensin system inhibitors (RASi) and clinical outcomes of patients with heart failure (HF) undergoing cardiac surgery. Summary Background Data: It is controversial whether the perioperative RASi should be administered in HF patients undergoing cardiac surgery. Methods: A total of 2338 patients with HF and undergoing CABG and/ or valve surgeries at multiple hospitals from 2001 to 2015 were identified from STS database. After adjustment using propensity score and instrumental variable, logistic regression was conducted to analyze the influence of preoperative continuation of RASi (PreRASi) on short-term in-hospital outcomes. Independent risk factors of 30-day mortality, major adverse cardiovascular events (MACE), and renal failure were analyzed by use of stepwise logistic regression. The effects of pre-and postoperative use of RASi (PostRASi) on long-term mortality were analyzed using survival analyses. Stepwise Cox regression was conducted to analyze the independent risk factors of 6-year mortality. The relationships of HF status and surgery type with perioperative RASi, as well as PreRASi-PostRASi, were also evaluated by subgroup analyses. Results: PreRASi was associated with lower incidences of 30-day mortality [P < 0.0001, odds ratio (OR): 0.556, 95% confidence interval (CI) 0.405−0.763], stroke (P =0.035, OR: 0.585, 95% CI: 0.355−0.962), renal failure (P =0.007, OR: 0.663, 95% CI: 0.493-0.894). Both PreRASi (P =0.0137) and PostRASi (P =0.007) reduced 6-year mortality compared with the No-RASi groups. Conclusions: Pre-and postoperative use of RASi was associated with better outcomes for the patients who have HF and undergo CABG and/ or valve surgeries. Preoperative continuation and postoperative restoration are warranted in these patients.

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Section: Discussionmentioning

confidence: 76%

Perioperative Renin–Angiotensin System Inhibitors Improve Major Outcomes of Heart Failure Patients Undergoing Cardiac Surgery

et al. 2022

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“…Our study focused only on the effects of antihypertensive medication on postoperative mortality and functional decline during the acute phase of hospitalization following major surgeries. A previous multicenter retrospective cohort study showed that the postoperative initiation of RASis even at discharge was associated with reduced long-term mortality rate in patients undergoing cardiac surgery [39]. Randomized controlled trials are needed to determine whether perioperative RASi initiation could improve outcomes following cardiac and non-cardiac surgeries.…”

Section: Discussionmentioning

confidence: 99%

Association between antihypertensive combinations and postoperative mortality and functional decline: a nationwide survey of Japanese adults undergoing major surgeries

Suzukawa,

Mandai,

Nakano

et al. 2024

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Background: Considering the limited information available regarding the impact of antihypertensive classes on mortality and physical function during hospitalization, we aimed to clarify the impact of six antihypertensive classes, namely thiazide/thiazide-like diuretics (TH), calcium receptor blockers (CCBs), renin-angiotensin-aldosterone system inhibitors (RASis), mineral corticoid receptor antagonists, α-blockers, and β-blockers, on outcomes in adult patients undergoing major surgeries. Methods: This study was a subanalysis of a nationwide observational cohort study involving Japanese adults undergoing major surgeries from 2018 to 2019 using an administrative claims database. We recruited 473,327 antihypertensive medication users and 376,583 nonusers aged ≥50 years who underwent six different types of surgeries, including coronary artery bypass grafting (CABG), thoracic lobectomy, orthopedic surgery, hepatopancreatobiliary surgery, gastrointestinal resection, and urological surgery. The risk for overall death or functional decline, defined as a >5-point decrease in the Barthel Index score during hospitalization, was determined using multivariable logistic regression models. Results: All-cause inhospital deaths occurred in 5,777 (1.2%) users and 2,657 (0.7%) nonusers. Functional decline was observed in 42,930 (9.2%) users and 22,550 (6.0%) nonusers. Among single class users, RASi use had a multivariable odds ratio (OR) of 0.77 (95% confidence interval (CI) 0.63-0.93 vs. TH) for the composite of mortality and functional decline. β-Blocker use was associated with an increased risk for functional decline (OR 1.27, 95% CI 1.01-1.60 vs. TH). Among the recipients of the two medication classes, TH/RASi usage was associated with the lowest risk for composite outcome (OR 0.68, 95% CI 0.60-0.77 vs. TH/CCB). Among the recipients of the three or more medication classes, TH/CCB/RASi or TH/CCB/RASi/other displayed the lowest odds for composite outcome (OR 0.72, 95% CI 0.49-0.82 vs. TH/CCB/other; OR 0.63, 95% CI 0.49-0.82 vs. TH/CCB/others). A stratified analysis revealed that RASi users had a lower OR for the composite outcome after major surgery categories except CABG than non-RASi users. Conclusions: RASis were associated with decreased risk of postoperative mortality and functional decline regardless of the number of antihypertensive classes or surgery type. Managing hypertension through multidrug combinations, including RASis, may mitigate mortality and loss of physical function during the perioperative period.

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“…Despite this, RAS blockade is still not recommended before cardiovascular surgery. Current randomized trials are underway to appropriately assess the pre-operative use of RAS blockade in patients undergoing heart surgery [ 31 ].…”

Section: Discussionmentioning

confidence: 99%

ARNI Pre-Operative Use and Vasoplegic Syndrome in Patients Undergoing Heart Transplantation or Left Ventricular Assist Device Surgery

et al. 2021

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Background: Vasoplegic syndrome after orthotopic heart transplantation (OHT) or left ventricular assist device (LVAD) implantation is a rare but highly lethal syndrome with complex etiologies. The objective of this study was to assess if the preoperative use of sacubitril-valsartan combination is associated with an increased vasoplegic syndrome (VS) frequency after OHT or LVAD implantation and its relationship with 30-day mortality. Methods: A retrospective review of perioperative data, between January 2016 and December 2017, from 73 consecutive OHT and LVAD surgery adult patients at our institution was performed. VS was defined as normal cardiac output with persistent low systemic resistance requiring a norepinephrine intravenous perfusion > 0.5 µg/kg/min and the absence of sepsis or hemorrhagic shock within 48 h after surgery. Patients were all followed-up for adverse events and all-cause mortality at 30 days. Results: In our cohort of 73 patients (median age 51.7 years, 65% male patients), 25 (34%) patients developed VS. Twenty-two (30.1%) patients were on ARNI at the time of surgery, 31 (42.5%) were on other RAS blockers, 12 (16.4%) were on norepinephrine and 8 (11%) had no pre-operative drug. The pre-operative use of any vasoactive agent, was not significantly associated with VS (OR = 1.36; IC95% [0.78; 2.35]; p = 0.38). The pre-operative use of an ARNI compared to all other groups was not significantly associated with VS (OR = 2.0; IC95% [0.71; 5.62]; p = 0.19). The pre-operative use of an ARNI compared to other RAS blockers was also not significantly associated with VS (OR = 1.25; IC95% [0.37; 4.26]; p = 0.72). At 30 days, 18 (24.7%) patients had died. The pre-operative treatment with ARNI, or other RAS inhibitors was associated with a significantly lower rate of death compared to the absence of treatment (HR = 0.11; IC95% [0.02; 0.55]; p = 0.009 for ARNI and HR = 0.20; IC95% [0.06; 0.69]; p = 0.011 for other RASi). Conclusions: Preoperative use of sacubitril-valsartan was not significantly associated with development of vasoplegic syndrome in patients undergoing OHT or LVAD surgery. Furthermore, our data suggests a significant 30-day survival benefit with efficient renin-angiotensin blockade before surgery.

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

Cited by 17 publications

References 44 publications

Perioperative Renin–Angiotensin System Inhibitors Improve Major Outcomes of Heart Failure Patients Undergoing Cardiac Surgery

Perioperative Renin–Angiotensin System Inhibitors Improve Major Outcomes of Heart Failure Patients Undergoing Cardiac Surgery

Association between antihypertensive combinations and postoperative mortality and functional decline: a nationwide survey of Japanese adults undergoing major surgeries

ARNI Pre-Operative Use and Vasoplegic Syndrome in Patients Undergoing Heart Transplantation or Left Ventricular Assist Device Surgery

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