Patterns of use of perioperative angiotensin-converting enzyme inhibitors in coronary artery bypass graft surgery with cardiopulmonary bypass: effects on in-hospital morbidity and mortality
Benjamin Drenger, Manuel L Fontes, Yinghui Miao, Joseph P Mathew, Yaacov Gozal, Solomon Aronson, Cynthia Dietzel, Dennis T Mangano, Investigators of the Ischemia Research and Education Foundation, Multicenter Study of Perioperative Ischemia Research Group, S Aronson, M Comunale, M D'Ambra, M Eaton, R Engelman, J Fitch, K Grichnik, C B Hantler, Z Hillel, M Kanchuger, J Ostrowski, C M Mangano, J Mathew, M Fontes, P Barash, M McSweeney, R Wolman, C A Napolitano, L A Nesbitt, N Nijhawan, N Nussmeier, E G Pivalizza, S Polson, J Ramsay, G Roach, N Schwann, S Shenaq, K Shevde, L Shore-Lesserson, D Bronheim, J Wahr, B Spiess, I Wright, A Wallace, H Metzler, D Ansley, J P O'Connor, D Cheng, D Côte, P Duke, J Y Dupuis, M Hynes, B Finegan, R Martineau, P Couture, D Mazer, J C Villalba, M E Colmenares, C Girard, C Isetta, C A Greim, N Roewer, A Hoeft, R Loeb, J Radke, T Mollhoff, J Motsch, E Martin, E Ott, J Scholz, P Tonner, H Sonntag, P Ueberfuhr, A Szekely, R Juneja, G Mani, B Drenger, Y Gozal, E Elami, C Tommasino, P Luna, P Roekaerts, S DeLange, R Pfitzner, D Filipescu, U Prakanrattana, D J R Duthie, R O Feneck, M A Fox, J D Park, D Smith, A Vohra, A Vuylsteke, R D Latimer, Benjamin Drenger, Manuel L Fontes, Yinghui Miao, Joseph P Mathew, Yaacov Gozal, Solomon Aronson, Cynthia Dietzel, Dennis T Mangano, Investigators of the Ischemia Research and Education Foundation, Multicenter Study of Perioperative Ischemia Research Group, S Aronson, M Comunale, M D'Ambra, M Eaton, R Engelman, J Fitch, K Grichnik, C B Hantler, Z Hillel, M Kanchuger, J Ostrowski, C M Mangano, J Mathew, M Fontes, P Barash, M McSweeney, R Wolman, C A Napolitano, L A Nesbitt, N Nijhawan, N Nussmeier, E G Pivalizza, S Polson, J Ramsay, G Roach, N Schwann, S Shenaq, K Shevde, L Shore-Lesserson, D Bronheim, J Wahr, B Spiess, I Wright, A Wallace, H Metzler, D Ansley, J P O'Connor, D Cheng, D Côte, P Duke, J Y Dupuis, M Hynes, B Finegan, R Martineau, P Couture, D Mazer, J C Villalba, M E Colmenares, C Girard, C Isetta, C A Greim, N Roewer, A Hoeft, R Loeb, J Radke, T Mollhoff, J Motsch, E Martin, E Ott, J Scholz, P Tonner, H Sonntag, P Ueberfuhr, A Szekely, R Juneja, G Mani, B Drenger, Y Gozal, E Elami, C Tommasino, P Luna, P Roekaerts, S DeLange, R Pfitzner, D Filipescu, U Prakanrattana, D J R Duthie, R O Feneck, M A Fox, J D Park, D Smith, A Vohra, A Vuylsteke, R D Latimer
Abstract
Background: Despite proven benefit in ambulatory patients with ischemic heart disease, the pattern of use of angiotensin-converting enzyme inhibitors (ACEIs) in coronary artery bypass graft surgery has been erratic and controversial.
Methods and results: This is a prospective observational study of 4224 patients undergoing coronary artery bypass graft surgery. The cohort included 1838 patients receiving ACEI therapy before surgery and 2386 (56.5%) without ACEI exposure. Postoperatively, the pattern of ACEI use yielded 4 groups: continuation, 915 (21.7%); withdrawal, 923 (21.8%); addition, 343 (8.1%); and no ACEI, 2043 (48.4%). Continuous treatment with ACEI versus no ACEI was associated with substantive reductions of risk of nonfatal events (adjusted odds ratio for the composite outcome, 0.69; 95% confidence interval, 0.52-0.91; P=0.009) and a cardiovascular event (odds ratio, 0.64; 95% confidence interval, 0.46-0.88; P=0.006). Addition of ACEI de novo postoperatively compared with no ACEI therapy was also associated with a significant reduction of risk of composite outcome (odds ratio, 0.56; 95% confidence interval, 0.38-0.84; P=0.004) and a cardiovascular event (odds ratio, 0.63; 95% confidence interval, 0.40-0.97; P=0.04). On the other hand, continuous treatment of ACEI versus withdrawal of ACEI was associated with decreased risk of the composite outcome (odds ratio, 0.50; 95% confidence interval, 0.38-0.66; P<0.001), as well as a decrease in cardiac and renal events (P<0.001 and P=0.005, respectively). No differences in in-hospital mortality and cerebral events were noted.
Conclusions: Our study suggests that withdrawal of ACEI treatment after coronary artery bypass graft surgery is associated with nonfatal in-hospital ischemic events. Furthermore, continuation of ACEI or de novo ACEI therapy early after cardiac surgery is associated with improved in-hospital outcomes.
Source: PubMed