Journal
ANESTHESIOLOGY
Volume 126, Issue 1, Pages 16-27Publisher
LIPPINCOTT WILLIAMS & WILKINS
DOI: 10.1097/ALN.0000000000001404
Keywords
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Categories
Funding
- Canadian Institutes of Health Research (Ottawa, Ontario, Canada) [MOP-93702, MOP-98001, MOP-93661, MSH-81729]
- Heart and Stroke Foundation of Ontario (Toronto, Ontario, Canada)
- Academic Health Science Centres Alternative Funding Plan Innovation Fund Grant (Toronto, Ontario, Canada)
- Population Health Research Institute Grant (Hamilton, Ontario, Canada)
- Clinical Advances Through Research and Information Translation Research Group Grant (Hamilton, Ontario, Canada)
- Department of Surgery, McMaster University (Hamilton, Ontario, Canada)
- Hamilton Health Science New Investigator Fund Grant (Hamilton, Ontario, Canada)
- Hamilton Health Sciences Grant (Hamilton, Ontario, Canada)
- Ontario Ministry of Resource and Innovation Grant (Toronto, Ontario, Canada)
- Stryker Canada (Waterdown, Ontario, Canada)
- Department of Anesthesiology, McMaster University (Hamilton, Ontario, Canada)
- Department of Medicine, Saint Joseph's Healthcare (Hamilton, Ontario, Canada)
- Father Sean O'Sullivan Research Centre (Hamilton, Ontario, Canada)
- Department of Medicine, McMaster University (Hamilton, Ontario, Canada)
- Roche-Diagnostics Global Office (Basel, Switzerland)
- Hamilton Health Sciences Summer Studentships (Hamilton, Ontario, Canada)
- Department of Clinical Epidemiology and Biostatistics, McMaster University Grant (Hamilton, Ontario, Canada)
- Division of Cardiology, McMaster University Grant (Hamilton, Ontario, Canada)
- Canadian Network and Centre for Trials Internationally Grant (Hamilton, Ontario, Canada)
- Winnipeg Health Sciences Foundation Operating Grant Winnipeg, Manitoba, Canada
- Department of Surgery, University of Manitoba Research Grant (Winnipeg, Manitoba, Canada)
- Diagnostic Services of Manitoba Research Grant (Winnipeg, Manitoba, Canada)
- Manitoba Medical Services Foundation Grant (Winnipeg, Manitoba, Canada)
- Manitoba Health Research Council Grant (Winnipeg, Manitoba, Canada)
- Faculty of Dentistry Operational Fund, University of Manitoba (Winnipeg, Manitoba, Canada)
- Department of Anesthesia, University of Manitoba Grant (Winnipeg, Manitoba, Canada)
- University Medical Group, Department of Surgery, University of Manitoba, start-up Fund (Winnipeg, Manitoba, Canada)
- National Health and Medical Research Council Program Grant (Canberra, Australia)
- Australian and New Zealand College of Anesthesiologists Grant (Sydney, Australia)
- Brazil: Projeto Hospitais de Excelencia a Servico do SUS grant from the Brazilian Ministry of Health
- Hcor (Cardiac Hospital Sao Paulo-SP
- Sao Paulo, Brazil)
- National Council for Scientific and Technological Development (Sao Paulo, Brazil)
- Public Policy Research Fund, Research Grant Council, Hong Kong SAR (Hong Kong)
- General Research Fund, Research Grant Council, Hong Kong SAR (Hong Kong)
- School of Nursing, Universidad Industrial de Santander (Bucaramanga, Colombia)
- Grupo de Cardiologia Preventiva, Universidad Autonoma de Bucaramanga (Bucaramanga, Colombia)
- Fundacion Cardioinfantil - Instituto de Cardiologia (Bogota, Colombia)
- Alianza Diagnostica S.A. (Bucaramanga, Colombia)
- Division of Clinical Research and Training Grant, St. John's Medical College and Research Institute Grant (Bangalore, India)
- University of Malaya Research Grant (Kuala Lumpur, Malaysia)
- University of Malaya, Penyelidikan Jangka Pendek Grant (Kuala Lumpur, Malaysia)
- Instituto de Salud Carlos III (Madrid, Spain)
- Fundacio La Marato de TV3 (Esplugues de Llobregat, Spain)
- American Heart Association Grant (Dallas, Texas)
- National Institute for Health Research (London, United Kingdom)
- Roche-Diagnostics (Mannheim, Germany)
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Background: The effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before noncardiac surgery is unknown. Methods: In this international prospective cohort study, the authors analyzed data from 14,687 patients (including 4,802 angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users) at least 45 yr old who had in-patient noncardiac surgery from 2007 to 2011. Using multivariable regression models, the authors studied the relationship between withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and a primary composite outcome of all-cause death, stroke, or myocardial injury after noncardiac surgery at 30 days, with intraoperative and postoperative clinically important hypotension as secondary outcomes. Results: Compared to patients who continued their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, the 1,245 (26%) angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users who withheld their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in the 24 h before surgery were less likely to suffer the primary composite outcome of all-cause death, stroke, or myocardial injury (150/1,245 [12.0%] vs. 459/3,557 [12.9%]; adjusted relative risk, 0.82; 95% CI, 0.70 to 0.96; P = 0.01) and intraoperative hypotension (adjusted relative risk, 0.80; 95% CI, 0.72 to 0.93; P < 0.001). The risk of postoperative hypotension was similar between the two groups (adjusted relative risk, 0.92; 95% CI, 0.77 to 1.10; P = 0.36). Results were consistent across the range of preoperative blood pressures. The practice of withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers was only modestly correlated with patient characteristics and the type and timing of surgery. Conclusions: Withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. A large randomized trial is needed to confirm this finding. In the interim, clinicians should consider recommending that patients withhold angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 24 h before surgery.
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