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  • No need to hold BP...

No need to hold BP meds for non-cardiac surgery- it fails to reduce heart injuries

Written By : Medha Baranwal |Medically Reviewed By : Dr. Kamal Kant Kohli Published On 2023-11-17T21:00:47+05:30  |  Updated On 18 Nov 2023 10:59 AM IST
No need to hold BP meds for non-cardiac surgery- it fails to reduce heart injuries
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UK: Some patients are briefly taken off their antihypertensive medications before non-cardiac surgery. Now, a recent study published in the European Heart Journal suggests that this practice may not work as intended and may be harmful.

Findings from the SPACE trial revealed that discontinuing renin-angiotensin system (RAS) inhibitors before non-cardiac surgery failed to reduce myocardial injury and could raise the risk of clinically significant acute hypertension.

In the randomized controlled trial involving 260 patients preoperative BP was greater when RAS inhibitors were stopped. 48% of patients sustained myocardial injury after stopping RAS inhibitors, compared with 41% of patients who continued therapy. Hypertensive adverse events were more frequent when RAS inhibitors were stopped, without impacting hypotension rates.

Haemodynamic instability is linked with peri-operative myocardial injury, especially in patients receiving RAS inhibitors (angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers). There is no clarity on whether stopping RAS inhibitors to minimise hypotension, or continuing RAS inhibitors to avoid hypertension, reduces peri-operative myocardial injury.

Therefore, Gareth L Ackland, Queen Mary University of London, Charterhouse Square, London, UK, and colleagues conducted a randomized, multi-centre, open-label trial to evaluate whether the discontinuation of RAS inhibitors would lessen myocardial injury and postoperative complications, whilst assessing whether avoidance of haemodynamic instability would reduce post-operative morbidity.

The study included patients aged ≥60 years undergoing elective non-cardiac surgery from 2017 to 2021. 262 were randomly assigned to either discontinue (n = 130) or continue RAS inhibitors (n = 132) prescribed for existing medical conditions in six UK centres. RAS inhibitors were withheld for different durations (2-3 days) before surgery, as per their pharmacokinetic profile.

The primary outcome of the study was determined as 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.

The study led to the following findings:

  • Myocardial injury occurred in 48.3% of patients randomized to discontinue, compared with 41.3% of patients who continued, RAS inhibitors [odds ratio (for continuing): 0.77].
  • Hypertensive adverse events were more frequent when RAS inhibitors were stopped [12.4%], compared with 5.3% who continued RAS inhibitors [odds ratio (for continuing): 0.4].
  • Hypotension rates were similar when RAS inhibitors were stopped [9.3%] or continued [8.4%].

"The main finding of this trial was the similarity in the incidence of myocardial injury between patients who discontinued and continued RAS inhibitors during the peri-operative period," the researchers wrote. "However, patients who discontinued RAS inhibitors did experience more hypertensive events."

"These findings require confirmation in future studies," they concluded.

Reference:

Ackland, G. L., Patel, A., Abbott, T. E., Begum, S., Dias, P., Crane, D. R., Somanath, S., Middleditch, A., Cleland, S., Brealey, D., Pearse, R. M., Ackland, G., Martin, T., Fernandez, M., Seidu, F., Pakats, M., Mahr, O., MacDonald, N., Dos Santos, F., . . . Harris, S. Discontinuation vs. Continuation of renin–angiotensin system inhibition before non-cardiac surgery: The SPACE trial. European Heart Journal. https://doi.org/10.1093/eurheartj/ehad716


European Heart Journalnon-cardiac surgeryrenin–angiotensin system inhibitorsRAS inhibitorsmyocardial injury
Source : European Heart Journal
Medha Baranwal
Medha Baranwal

    MSc. Biotechnology

    Dr. Kamal Kant Kohli
    Dr. Kamal Kant Kohli

    Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751

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