Portal de Periódicos da CAPES

Discontinuation vs. continuation of renin–angiotensin system inhibition before non-cardiac surgery: the SPACE trial

2023; Oxford University Press; Volume: 45; Issue: 13 Linguagem: Inglês

10.1093/eurheartj/ehad716

1522-9645

Gareth L. Ackland, Akshaykumar Patel, Tom Abbott, Salma Begum, Priyanthi Dias, David R Crane, Sameer Somanath, Alexander Middleditch, Stuart Cleland, Ana Gutierrez del Arroyo, David Brealey, Rupert M. Pearse, Gareth L. Ackland, Tim Martin, Maria Fernandez, Fatima Seidu, Mari-Liis Pakats, Otto Mahr, Neil MacDonald, Filipa Santos, Amaia Arrieta Garcia, Ruzena Uddin, Salma Begum, Rupert M. Pearse, Emily Subhedar, Yize I. Wan, Akshaykumar Patel, Tasnin Shahid, Mevan Gooneratne, Charlotte Trainer, Bethan Griffiths, Steven Dunkley, Shaun M. May, Sophie Walker, Alexander J. Fowler, Tim Stephens, Mônica Amorim de Oliveira, Marta Januszewska, Edyta Niebrzegowska, Vanessa Teixeira do Amaral, Jamila Kassam, Sophie Young, Shanaz Ahmad, Jan Whalley, Ryan W. Haines, Sara Hui, Rob Hammond, David Crane, David Brealey, Sohail Bampoe, Robert Stephens, Anna Reyes, Gladys Martir, C. Rios Diaz, Stuart Cleland, Gary Minto, Natasha Wilmshurst, Debbie-Claire Affleck, Tracy Ward, G. Werrett, Susan K. Cummins, Alan Amber, Andrew Biffen, Stephen Boumphrey, Elizabeth Cann, Charlotte Eglinton, Elaine Jones, Memory Mwadeyi, Sam Piesley, Richard Cowan, Julie Alderton, Fiona Reed, Joanne Smith, Amy S. Turner, Lorraine Madziva, Abigail Patrick, Penny Harris, Harry Lang, Alexander Middleditch, Anthony E. Pickering, Catherine O’Donovan, Rebecca Houlihan, Rosina Jarvis, Andrew Shrimpton, Toni Farmery, Katy Tucker, Danielle Davis, Sameer Somanth, Louise Duncan, H Melsom, Sarah L. Clark, Melanie Kent, Michelle A. Wood, A Laidlaw, Tracy Matheson-Smith, Kathryn Potts, Andrea Kay, Stefanie Hobson, John W. Sear, Vikas Kapil, Andrew Archbold, M.G.F. Wilson, Drilona Dndrejaj, Dennis Ly, Akshaykumar Patel, Toby Richards, Simon J. Finney, Steve Harris,

Heart Failure Treatment and Management

Abstract Background and Aims Haemodynamic instability is associated with peri-operative myocardial injury, particularly in patients receiving renin–angiotensin system (RAS) inhibitors (angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers). Whether stopping RAS inhibitors to minimise hypotension, or continuing RAS inhibitors to avoid hypertension, reduces peri-operative myocardial injury remains unclear. Methods From 31 July 2017 to 1 October 2021, patients aged ≥60 years undergoing elective non-cardiac surgery were randomly assigned to either discontinue or continue RAS inhibitors prescribed for existing medical conditions in six UK centres. Renin–angiotensin system inhibitors were withheld for different durations (2–3 days) before surgery, according to their pharmacokinetic profile. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury [plasma high-sensitivity troponin-T (hs-TnT) ≥ 15 ng/L within 48 h after surgery, or ≥5 ng/L increase when pre-operative hs-TnT ≥15 ng/L]. Pre-specified adverse haemodynamic events occurring within 48 h of surgery included acute hypertension (>180 mmHg) and hypotension requiring vasoactive therapy. Results Two hundred and sixty-two participants were randomized to continue (n = 132) or stop (n = 130) RAS inhibitors. Myocardial injury occurred in 58 (48.3%) patients randomized to discontinue, compared with 50 (41.3%) patients who continued, RAS inhibitors [odds ratio (for continuing): 0.77; 95% confidence interval (CI) 0.45–1.31]. Hypertensive adverse events were more frequent when RAS inhibitors were stopped [16 (12.4%)], compared with 7 (5.3%) who continued RAS inhibitors [odds ratio (for continuing): 0.4; 95% CI 0.16–1.00]. Hypotension rates were similar when RAS inhibitors were stopped [12 (9.3%)] or continued [11 (8.4%)]. Conclusions Discontinuing RAS inhibitors before non-cardiac surgery did not reduce myocardial injury, and could increase the risk of clinically significant acute hypertension. These findings require confirmation in future studies.