A systematic review of outcomes associated with withholding or continuing angiotensinconverting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) prior to noncardiac surgery
| dc.contributor.advisor | Biccard, Bruce | |
| dc.contributor.author | Hollmann, Caryl | |
| dc.date.accessioned | 2020-04-23T14:18:40Z | |
| dc.date.available | 2020-04-23T14:18:40Z | |
| dc.date.issued | 2019 | |
| dc.date.updated | 2020-04-23T01:18:40Z | |
| dc.description.abstract | Introduction The global rate of major noncardiac surgical procedures is increasing annually, and of those patients presenting for surgery increasing numbers are taking either an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin receptor blocker(ARB). The current recommendations whether to continue or withhold ACE-I and ARB in the perioperative period are conflicting. Previous metaanalyses have linked preoperative ACE-I /ARB therapy to the increased incidence of post induction hypotension, however have failed to correlate this with adverse patient outcomes. The aim of this meta-analysis was to determine whether continuation or withholding ACE-I or ARB therapy in the perioperative period is associated with mortality and major morbidity. Methods This meta-analysis was prospectively registered on PROSPERO (CRD42017055291). A comprehensive search of MEDLINE (PubMed), CINAHL (EBSCO host), ProQuest, Cochrane database, Scopus and Web of Science was conducted on 06 December 2016. We included adult patients >18years, on chronic ACE-I or ARB therapy who underwent noncardiac surgery, where ACE-I or ARB was either withheld or continued on the morning of surgery. Primary outcomes included all-cause mortality and major cardiac events (MACE). Secondary outcomes included the risk of congestive heart failure (CHF), acute kidney injury, stroke, intra/postoperative hypotension and the length of hospital stay (LOS). Results Following abstract review, the full text of 25 studies were retrieved, of which nine fulfilled the inclusion criteria; five were randomized control trials (RCTs) and four cohort studies. These studies included a total of 6022 patients on chronic ACE-I/ARB therapy prior to noncardiac surgery. 1816 patients withheld treatment the morning of surgery and 4206 continued their ACE-I/ARB. Preoperative demographics were similar between the two groups. Withholding ACE-I/ARB therapy was not associated with a difference in mortality (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.62-1.52; I2 =0%) or MACE (OR 1.12; 95% CI 0.82-1.52; I2 =0%). Withholding therapy was however associated with significantly less intra-operative hypotension (OR 0.63 95% CI 0.47;0.85, I 2 =71%). No effect estimate could be pooled concerning length of hospital stay and CHF. Conclusions This meta-analysis did not demonstrate an association between perioperative administration of ACEI/ARB, and mortality or MACE. It did however confirm the current observation that perioperative continuation of ACE-I/ARBs is associated with an increased incidence of intra-operative hypotension. A large randomized control trial is necessary to determine the appropriate perioperative management of ACE-I and ARBs. | |
| dc.identifier.apacitation | Hollmann, C. (2019). <i>A systematic review of outcomes associated with withholding or continuing angiotensinconverting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) prior to noncardiac surgery</i>. (). ,Faculty of Health Sciences ,Department of Anaesthesia and Perioperative Medicine. Retrieved from | en_ZA |
| dc.identifier.chicagocitation | Hollmann, Caryl. <i>"A systematic review of outcomes associated with withholding or continuing angiotensinconverting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) prior to noncardiac surgery."</i> ., ,Faculty of Health Sciences ,Department of Anaesthesia and Perioperative Medicine, 2019. | en_ZA |
| dc.identifier.citation | Hollmann, C. 2019. A systematic review of outcomes associated with withholding or continuing angiotensinconverting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) prior to noncardiac surgery. . ,Faculty of Health Sciences ,Department of Anaesthesia and Perioperative Medicine. | en_ZA |
| dc.identifier.ris | TY - Thesis / Dissertation AU - Hollmann, Caryl AB - Introduction The global rate of major noncardiac surgical procedures is increasing annually, and of those patients presenting for surgery increasing numbers are taking either an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin receptor blocker(ARB). The current recommendations whether to continue or withhold ACE-I and ARB in the perioperative period are conflicting. Previous metaanalyses have linked preoperative ACE-I /ARB therapy to the increased incidence of post induction hypotension, however have failed to correlate this with adverse patient outcomes. The aim of this meta-analysis was to determine whether continuation or withholding ACE-I or ARB therapy in the perioperative period is associated with mortality and major morbidity. Methods This meta-analysis was prospectively registered on PROSPERO (CRD42017055291). A comprehensive search of MEDLINE (PubMed), CINAHL (EBSCO host), ProQuest, Cochrane database, Scopus and Web of Science was conducted on 06 December 2016. We included adult patients >18years, on chronic ACE-I or ARB therapy who underwent noncardiac surgery, where ACE-I or ARB was either withheld or continued on the morning of surgery. Primary outcomes included all-cause mortality and major cardiac events (MACE). Secondary outcomes included the risk of congestive heart failure (CHF), acute kidney injury, stroke, intra/postoperative hypotension and the length of hospital stay (LOS). Results Following abstract review, the full text of 25 studies were retrieved, of which nine fulfilled the inclusion criteria; five were randomized control trials (RCTs) and four cohort studies. These studies included a total of 6022 patients on chronic ACE-I/ARB therapy prior to noncardiac surgery. 1816 patients withheld treatment the morning of surgery and 4206 continued their ACE-I/ARB. Preoperative demographics were similar between the two groups. Withholding ACE-I/ARB therapy was not associated with a difference in mortality (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.62-1.52; I2 =0%) or MACE (OR 1.12; 95% CI 0.82-1.52; I2 =0%). Withholding therapy was however associated with significantly less intra-operative hypotension (OR 0.63 95% CI 0.47;0.85, I 2 =71%). No effect estimate could be pooled concerning length of hospital stay and CHF. Conclusions This meta-analysis did not demonstrate an association between perioperative administration of ACEI/ARB, and mortality or MACE. It did however confirm the current observation that perioperative continuation of ACE-I/ARBs is associated with an increased incidence of intra-operative hypotension. A large randomized control trial is necessary to determine the appropriate perioperative management of ACE-I and ARBs. DA - 2019 DB - OpenUCT DP - University of Cape Town KW - Anaesthesiology LK - https://open.uct.ac.za PY - 2019 T1 - A systematic review of outcomes associated with withholding or continuing angiotensinconverting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) prior to noncardiac surgery TI - A systematic review of outcomes associated with withholding or continuing angiotensinconverting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) prior to noncardiac surgery UR - ER - | en_ZA |
| dc.identifier.uri | https://hdl.handle.net/11427/31682 | |
| dc.identifier.vancouvercitation | Hollmann C. A systematic review of outcomes associated with withholding or continuing angiotensinconverting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) prior to noncardiac surgery. []. ,Faculty of Health Sciences ,Department of Anaesthesia and Perioperative Medicine, 2019 [cited yyyy month dd]. Available from: | en_ZA |
| dc.language.rfc3066 | eng | |
| dc.publisher.department | Department of Anaesthesia and Perioperative Medicine | |
| dc.publisher.faculty | Faculty of Health Sciences | |
| dc.subject | Anaesthesiology | |
| dc.title | A systematic review of outcomes associated with withholding or continuing angiotensinconverting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) prior to noncardiac surgery | |
| dc.type | Master Thesis | |
| dc.type.qualificationlevel | Masters | |
| dc.type.qualificationname | MMed |