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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
Study Question: Is there an association of ACE inhibitor (ACEI) administration and on-pump coronary artery bypass graft (CABG) surgery with clinical outcomes?
Study Description: This study was a prospective multinational observational study of 4,224 patients undergoing CABG surgery (nonvalvular) treated with any dose ACEI (ARBs not included). Patients were divided into the following groups: continuation (on an ACEI pre-op and post-op), withdrawal (on an ACEIpre-op but stopped post-op), addition (not on ACEI pre-op but started post-op), and no ACEI (ACEI never started). The primary outcome was a composite of cardiac, cerebral, and renal events and in-hospital mortality.
Results: Patients in the no ACEI group had fewer comorbidities, while patients treated with ACEI prior to surgery had longer on-pump times. The continuation group had a 31% lower odds of the composite outcome (p=0.009) versus no ACEI, however the continuation group required more non-routine inotropes (28.1% vs 13.8%, p<0.001) despite having similar cardiac indices. The continuation group had a 50% lower odds of the composite outcome (p<0.001) versus the withdrawal group as well as significantly lower use of transfusion and cardiac assist devices (p<0.001). The addition group had a 44% lower odds of the composite outcome (p=0.004) versus the no ACEI group.
Conclusion: Discontinuation of ACEI following CABG is associated with nonfatal in-hospital ischemic events.
Perspective: The results of this study should serve as a launching point for a large randomized controlled trial to definitively dictate appropriate ACEI (or even RAAS blocking) therapy in these patients. We can see parallels to the benefits seen with beta-blockers in this population, yet must give pause with non-protocolized postoperative management. At minimum the results should require us to analyze the current practice of discontinuation of preoperative ACEI.