作者
Gareth L. Ackland,Akshaykumar Patel,Tom Abbott,Salma Begum,Gareth L. Ackland,David 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 Maseda García,Ruzena Uddin,Salma Begum,Rupert M Pearse,Emily Subhedar,Yize I. Wan,Akshaykumar Patel,Tasnin Shahid,Mevan Gooneratne,Charlotte Trainer,B 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,Chimverly Diaz,Stuart Cleland,Gary Minto,Natasha Wilmshurst,David G. Affleck,Tracy Ward,G. Werrett,Susan K. Cummins,A. Binti Amber,Andrew Biffen,Stephen Boumphrey,Elizabeth Cann,Charlotte Eglinton,E Jones,Memory Mwadeyi,Sam Piesley,Richard Cowan,Julie Alderton,Frank R. Reed,J. D. Smith,Amy S Turner,Lorraine Madziva,Abigail Patrick,Penny Harris,Hans J. 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,Ann Laidlaw,Tracy Matheson-Smith,Kathryn Potts,Andrea Kay,Shirley M. Hobson,J.W. Sear,Vikas Kapil,R. Andrew Archbold,Matt Wilson,Drilona Dndrejaj,David Ly,Akshaykumar Patel,Toby Richards,Simon J. Finney,Steve Harris
摘要
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.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.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%)].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.