Do ACE inhibitors increase mortality in CABG patients?

"The study will be published in an upcoming issue of the Journal of the American College of Cardiology and was published online August 13, 2009."

Do ACE inhibitors increase mortality in CABG patients?
August 12, 2009 | Shelley Wood
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Bristol, UK - Authors of a large, observational study say preoperative use of ACE inhibitors may double the risk of dying after CABG surgery [1]. Dr Antonio Miceli (University of Bristol, UK) and colleagues say their findings support a strategy of stopping ACE inhibitors presurgery and then restarting them postoperatively. But not everyone agrees with the results of the new analysis: commenting on the study for heartwire, Dr Harold Lazar (Boston University School of Medicine, MA) argued that there are some patients in whom ACE inhibitors should not be stopped, particularly patients with hypertension and/or diabetes, who have had a recent MI.

The study will be published in an upcoming issue of the Journal of the American College of Cardiology and was published online August 13, 2009.

Miceli et al's research adds a generous dollop of data to an already confusing mélange of studies supporting or rejecting a role for ACE inhibitors in CABG patients. As Miceli et al explain, ACE inhibitors lower blood pressure and have antiatherosclerotic, antithrombotic, and anti-inflammatory effects—all of which paved the way for recommendations to use them in patients with coronary artery disease. But their effect when used preoperatively in CABG patients "is still controversial," they note.


Miceli et al's research adds a generous dollop of data to an already confusing mélange of studies supporting or rejecting a role for ACE inhibitors in CABG patients. As Miceli et al explain, ACE inhibitors lower blood pressure and have antiatherosclerotic, antithrombotic, and anti-inflammatory effects—all of which paved the way for recommendations to use them in patients with coronary artery disease. But their effect when used preoperatively in CABG patients "is still controversial," they note.

To gauge these effects, Miceli and colleagues reviewed data on preoperative ACE-inhibitor use among more than 10 000 patients who had CABG surgery between April 1996 and May 2008 at the Bristol Heart Institute, UK. In all, 3052 were taking ACE inhibitors prior to their surgery and were matched with a control group using propensity scores.

Miceli et al report that the mortality rate in the ACE-inhibitor group was nearly double that of patients not taking ACE inhibitors: 1.3% vs 0.7%. As well, new-onset atrial fibrillation, renal dysfunction, and use of inotropic support were all higher among patients taking ACE inhibitors preoperatively. Use of ACE inhibitors remained an independent predictor of mortality after multivariate analysis.

Postoperative outcomes

Outcome
ACE inhibitors (%)
Control (%)
Odds ratio (95% CI)
p

Mortality
1.3
0.7
2.0 (1.17-3.42)
0.013

Atrial fibrillation
25
20
1.34 (1.18-1.51)
<0.0001

Renal dysfunction
7.1
5.4
1.36 (1.1-1.67)
0.006

Use of inotropic support
45.9
41.1
1.22 (1.1-1.36)
<0.0001

http://www.theheart.org/article/991519.do