Pre-operative maintenance of angiotensin-converting enzyme inhibitors is not associated with acute kidney injury in cardiac surgery patients with cardio-pulmonary bypass: a propensity-matched multicentric analysis

Objective: We investigated the effects of the maintenance of angiotensin-converting enzyme inhibitors (ACE inhibitors) the day of the surgery on the incidence of postoperative acute kidney injury (AKI) and cardiac events in patients undergoing cardiac surgery. Methods: We performed a multicentric observational study with propensity matching on 1,072 patients treated with ACE inhibitors. We collected their baseline demographic data, comorbidities, and operative and postoperative outcomes. AKI was defined by KDIGO (Kidney Disease: Improving Global Outcome). Results: Maintenance of an ACE inhibitor was not associated with an increased risk of AKI (OR: 1.215 (CI95%:0.657-2.24), p = 0.843, 71 patients (25.1%) vs. 68 patients (24%)). Multivariate logistic regression and sensitive analysis did not demonstrate any association between ACE inhibitor maintenance and AKI, following cardiac surgery (OR: 1.03 (CI95%:0.81-1.3)). No statistically significant difference occurs in terms of incidence of cardiogenic shock (OR: 1.315 (CI95%:0.620-2.786)), stroke (OR: 3.313 (CI95%:0.356-27.523)), vasoplegia (OR: 0.741 (CI95%:0.419-1.319)), postoperative atrial fibrillation (OR: 1.710 (CI95%:0.936-3.122)), or mortality (OR: 2.989 (CI95%:0.343-26.034)). ICU and hospital length of stays did not differ (3 [2; 5] vs. 3 [2; 5] days, p = 0.963 and 9.5 [8; 12] vs. 10 [8; 14] days, p = 0.638). Conclusion: Our study revealed that maintenance of ACE inhibitors on the day of the surgery was not associated with increased postoperative AKI. ACE inhibitor maintenance was also not associated with an increased rate of postoperative major cardiovascular events (arterial hypotension, cardiogenic shock, vasopressors use, stroke and death).

Hypertension Requiring Medication Use: a Silent Predictor of Poor Outcomes After Pancreaticoduodenectomy

BACKGROUND

Although hypertension requiring medication (HTNm) is a well-known cardiovascular comorbidity, its association with postoperative outcomes is understudied. This study aimed to evaluate whether preoperative HTNm is independently associated with specific complications after pancreaticoduodenectomy.

STUDY DESIGN

Adults undergoing elective pancreaticoduodenectomy were included from the 2014-2019 NSQIP-targeted pancreatectomy dataset. Multivariable regression models compared outcomes between patients with and without HTNm. Endpoints included significant complications, any complication, unplanned readmissions, length of stay (LOS), clinically relevant postoperative pancreatic fistula (CR-POPF), and cardiovascular and renal complications. A subgroup analysis excluded patients with diabetes, heart failure, chronic obstructive pulmonary disease, estimated glomerular filtration rate from serum creatinine (eGFRCr) < 60 ml/min per 1.73 m², bleeding disorder, or steroid use.

RESULTS

Among 14,806 patients, 52% had HTNm. HTNm was more common among older male patients with obesity, diabetes, congestive heart failure, chronic obstructive pulmonary disease, functional dependency, hard pancreatic glands, and cancer. After adjusting for demographics, preoperative comorbidities, and laboratory values, HTNm was independently associated with higher odds of significant complications (aOR 1.12, p = 0.020), any complication (aOR 1.11, p = 0.030), cardiovascular (aOR 1.78, p = 0.002) and renal (aOR 1.60, p = 0.020) complications, and unplanned readmissions (aOR 1.14, p = 0.040). In a subgroup analysis of patients without major preoperative comorbidity, HTNm remained associated with higher odds of significant complications (aOR 1.14, p = 0.030) and cardiovascular complications (aOR 1.76, p = 0.033).

CONCLUSIONS

HTNm is independently associated with cardiovascular and renal complications after pancreaticoduodenectomy and may need to be considered in preoperative risk stratification. Future studies are necessary to explore associations among underlying hypertension, specific antihypertensive medications, and postoperative outcomes to investigate potential risk mitigation strategies.

An empirical comparison of the harmful effects for randomized controlled trials and non-randomized studies of interventions

Introduction: Randomized controlled trials (RCTs) are the gold standard to evaluate the efficacy of interventions (e.g., drugs and vaccines), yet the sample size of RCTs is often limited for safety assessment. Non-randomized studies of interventions (NRSIs) had been proposed as an important alternative source for safety assessment. In this study, we aimed to investigate whether there is any difference between RCTs and NRSIs in the evaluation of adverse events. Methods: We used the dataset of systematic reviews with at least one meta-analysis including both RCTs and NRSIs and collected the 2 × 2 table information (i.e., numbers of cases and sample sizes in intervention and control groups) of each study in the meta-analysis. We matched RCTs and NRSIs by their sample sizes (ratio: 0.85/1 to 1/0.85) within a meta-analysis. We estimated the ratio of the odds ratios (RORs) of an NRSI against an RCT in each pair and used the inverse variance as the weight to combine the natural logarithm of ROR (lnROR). Results: We included systematic reviews with 178 meta analyses, from which we confirmed 119 pairs of RCTs and NRSIs. The pooled ROR of NRSIs compared to that of RCTs was estimated to be 0.96 (95% confidence interval: 0.87 and 1.07). Similar results were obtained with different sample size subgroups and treatment subgroups. With the increase in sample size, the difference in ROR between RCTs and NRSIs decreased, although not significantly. Discussion: There was no substantial difference in the effects between RCTs and NRSIs in safety assessment when they have similar sample sizes. Evidence from NRSIs might be considered a supplement to RCTs for safety assessment.

Perioperative Care Standards in Cardiac Surgery Patients Aiming at Enhancing Recovery: A Nationwide Survey in the Netherlands and Belgium

OBJECTIVE

The aim of this survey was to describe existing perioperative care standards and best practices in the Netherlands and Belgium.

DESIGN

An online survey was followed up by an in-depth personal interview. The main outcomes were the existing standards of perioperative care for patients undergoing cardiac surgery.

SETTING

The online survey and subsequent interviews were targeted to one representative in the intensive care unit (ICU), cardiac surgery, and anesthesiology department from each cardiac surgical center in the Netherlands and Belgium.

PARTICIPANTS

A representative intensive care physician, cardiac surgeon, and cardiac anesthesiologist.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The response rate was 60% (71% for the Netherlands, and 44% in Belgium). Agreement across centers was found for discontinuation of proton-pump inhibitors (80%) and avoiding intra- and postoperative (92%) nonsteroidal antiinflammatory drugs. Additionally, 98% of respondents stated that physiotherapy should be started immediately in the ICU. Major divergence was found for elements such as the discontinuation of angiotensin-converting enzyme inhibitors (55%) or the postoperative use of chest support vests (44%).

CONCLUSIONS

The authors demonstrated a wide range of different local protocols. Strategies differed among disciplines, hospitals, and countries. This emphasized the need for the implementation of a more universal protocol to further reduce variance and improve recovery practices. This nationwide survey was the first of its kind simultaneously studying best practices for cardiac surgery through the entire care pathway at the advent of Enhanced Recovery After Surgery (ERAS) Cardiac implementation. A multinational randomized controlled trial to test the implementation of an evidence-based ERAS Cardiac protocol is the next step to pave the way for further outcome improvements in this high-risk population.

Impact of Renin-Angiotensin System Blockers on Mortality in Veterans Undergoing Cardiac Surgery

Background

Renin‐angiotensin system blockers (RASBs) have well‐validated benefit in patients with hypertension, coronary artery disease, and left ventricular systolic dysfunction. Their use in the perioperative period, however, has been controversial, including in patients undergoing cardiac surgery, who often have a strong indication for their use. In the current study, we explore the impact of RASB use with 30‐day and 1‐year mortality after cardiac surgery.

Methods and Results

The Veterans Affairs Surgical Quality Improvement Program and Corporate Data Warehouse were data sources for this retrospective cohort study. A total of 37 197 veterans undergoing elective coronary artery bypass grafting and or valve repair or replacement over a 10‐year period met inclusion criteria and were stratified into 4 groups by preoperative exposure (preoperative exposure versus no preoperative exposure) and postoperative continuing exposure (current exposure versus no current exposure) to RASBs. After adjusting for all baseline covariates, the preoperative exposure/current exposure group had lower 30‐day and 1‐year mortality than the preoperative exposure/no current exposure (30‐day hazard ratio [HR], 0.25; 95% CI, 0.19–0.33 [P<0.001] and 1‐year HR, 0.40; 95% CI, 0.33–0.48 [P<0.001] or no preoperative exposure/no current exposure (30‐day HR, 0.44; 95% CI, 0.32–0.60 [P<0.001] and 1‐year HR, 0.72; 95% CI, 0.62–0.84 [P<0.001] groups. The no preoperative exposure/current exposure group had significantly lower 30‐day (HR, 0.31; 95% CI, 0.14–0.71 [P=0.006]) and 1‐year (HR, 0.64; 95% CI, 0.53–0.77 [P<0.001]) mortality than the no preoperative exposure/no current exposure group.

Conclusions

Continuation of preoperative RASBs and initiation before discharge is associated with decreased mortality in veterans undergoing cardiac surgery. Given these findings, continuation of preoperative RASBs or initiation in the early postoperative period should be considered in patients undergoing cardiac surgery.

Angiotensin-Converting Enzyme Inhibitor/Receptor Blocker, Diuretic, or Nonsteroidal Anti-inflammatory Drug Use After Major Surgery and Acute Kidney Injury: A Case-Control Study

BACKGROUND

Acute kidney injury (AKI) is common after surgery and associated with increased mortality, costs, and lengths of hospitalization. We examined associations between angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), diuretic, or nonsteroidal anti-inflammatory drug (NSAID) use after major surgery and AKI.

MATERIALS AND METHODS

We conducted a nested case-control study of patients who underwent major cardiac, thoracic, general, or vascular surgery in Calgary, Alberta, Canada. Cases with AKI were matched on age, gender, and surgery type with up to five controls without AKI within 30-d after surgery. Adjusted odds ratios (ORs) for AKI were determined based on postoperative administration of ACEIs/ARBs, diuretics, or NSAIDs.

RESULTS

Among 33,648 patients in the cohort, 2911 cases with AKI were matched to 9309 controls without AKI. Postoperative diuretic [OR = 1.96; 95% confidence interval (CI) = 1.68-2.29], but not ACEI/ARB (OR = 0.83; 95% CI = 0.72-0.95) or NSAID (OR = 1.12; 95% CI = 0.96-1.31), use was independently associated with higher odds of AKI (including stages 1 and 2/3 AKI) after all types of major surgery. There were increased adjusted odds of AKI 1 to 5 d after first exposure to diuretics and 1 d after first exposure to NSAIDs (but not after later exposures). Relationships between ACEI/ARB use and AKI varied by surgery type (p-interaction = 0.004), with lower odds of AKI observed among ACEI/ARB use after cardiac surgery (OR = 0.70; 95% CI = 0.57-0.81), but no difference after other major surgeries.

CONCLUSIONS

Postoperative administration of diuretics and NSAIDs was associated with increased odds of AKI after major surgery. These findings characterize potentially modifiable medication exposures associated with AKI after surgery.

Secondary Prevention Medications Post Coronary Artery Bypass Grafting Surgery-A Literature Review

Secondary prevention after coronary artery bypass graft (CABG) surgery is imperative in slowing the progression of atherosclerosis in both native and grafted vessels. Aspirin and statins remain the key medications for all patients without significant contraindications. The evidence for dual antiplatelet therapy with clopidogrel is less convincing, but there is hope for newer antiplatelet agents, such as ticagrelor. Meanwhile, β-blockers and angiotensin converting enzyme inhibitors might only offer benefits to specific sub-groups. Post-CABG patients appear to have different medication needs to the general cardiovascular patient and respond differently. In this review, we cover the drug regimens proposed by recent guidelines and the evidence behind their use. Assessing the evidence behind these recommendations, we find that there is an unmet need in some areas for robust population-specific evidence. We hope that future research will address this gap.

The Effect of Renin-Angiotensin System Inhibitors on the Recurrence of Atrial Fibrillation After Catheter Ablation

Atrial fibrillation (AF) is the most common sustained arrhythmia. Renin-angiotensin system (RAS) inhibitors were reported to modify the arrhythmia substrate and reverse atrial remodeling. However, the role of RAS inhibitors on AF recurrence after catheter ablation remains much more controversial. In this study, a meta-analysis was performed to explore the effect of RAS inhibitors on AF recurrence after catheter ablation.We searched PubMed, Cochrane Library, EMBASE, and Web of Science for all articles published up to July 2019 on the effect of RAS inhibitors on AF recurrence rate after ablation. We used the random-effects model to estimate the odds ratios (ORs) and confidence intervals (CI). The I2 statistic was used to evaluate statistical heterogeneity. A two-tailed P value of <0.05 was considered statistically significant. Results were further analyzed by subgroup according to the type of study design.We included 13 studies, including 3661 patients with AF, in this analysis, of which 4 were randomized controlled trials (RCTs) and the others were cohort studies. Overall, treatment with RAS inhibitors showed a significant reduction of AF recurrence after catheter ablation (OR, 0.61; 95% CI, 0.45-0.82). Additionally, both the RCT (OR, 0.35; 95% CI, 0.24-0.49) and non-RCT (OR, 0.76; 95% CI, 0.57-1.00) groups demonstrated that RAS inhibitors could reduce the AF recurrence rate after catheter ablation in the subgroup analysis.Our meta-analysis suggests that RAS inhibitors had significant benefit in reducing the recurrence rate of AF after catheter ablation.

Predictors of Acute Kidney Injury Following Surgical Valve Replacement

BACKGROUND

 Acute kidney injury is a serious complication after surgical valve replacement and holds increased mortality rates.

OBJECTIVES

 To study predictors of acute kidney injury after surgical valve replacement.

MATERIALS AND METHODS

 Patients who underwent valve surgery procedures at our center were included. Procedures included aortic valve replacement (AVR), mitral valve replacement (MVR), AVR with coronary artery bypass grafting (CABG), MVR with CABG, or AVR and MVR with/without CABG.

RESULTS

 A total of 346 patients were included. The mean age was 51.56 (16.1). Males (n = 178) comprised 51%.At the univariate level analysis, predictors of acute kidney injury were found including age, ejection fraction, hypertension, history of CAD, emergency surgery, recent myocardial infarction, diabetes, atrial fibrillation, history of heart failure, mitral regurgitation (MR), pump time >120 minutes, aortic cross clamp >90 minutes, perioperative blood transfusion, re-exploration for bleeding, use of mechanical and biologic valve in aortic position, use of biologic valve in mitral position, prolonged inotropic support, postoperative stroke, and use of angiotensin converting enzyme inhibitors (ACEi) < a month, (all p < 0.05).By Logistic regression analysis, Age (p < 0.0001, odds ratio[AOR] = 1.076), hypertension (p = 0.039, AOR = 1.829), heart failure (p = 0.019, AOR = 2.448), MR (p = 0.0001, AOR = 3.110), use of ACEi <month (p = 0.043, AOR= 2.181), pump time >120 minutes (p = 0.022, AOR = 1.797), perioperative blood transfusion (p = 0.008, AOR = 2.532), and prolonged inotropic support (p = 0.012, AOR = 2.591) were significant and independent predictors of AKI.

CONCLUSION

 Independent predictors of acute kidney injury following valve surgeries include age, hypertension, heart failure, MR, use of ACEi <month, perioperative blood transfusion, and prolonged pump time or inotropic support.

Digital chest drainage system versus traditional chest drainage system after pulmonary resection: a systematic review and meta-analysis

BACKGROUND

Several randomized controlled trials (RCTs) and observational studies have compared the efficacy of digital chest drainage system versus traditional chest drainage system. However, the results were inconsistent.

METHODS

We searched the Web of Science and Pubmed for observational studies and RCTs that compared the effect of digital chest drainage system with traditional chest drainage system after pulmonary resection. Eight studies (5 randomized control trails and 3 observational studies) comprising 1487 patients met the eligibility criteria.

RESULTS

Compared with the traditional chest drainage system, digital chest drainage system reduced the risk of prolonged air leak (PAL) (RR = 0.54, 95%CI 0.40-0.73, p < 0.0001), and shortened the duration of chest drainage (SMD = - 0.35, 95%CI -0.60 - -0.09, p = 0.008) and length of hospital stay (SMD = - 0.35, 95%CI -0.61 - -0.09, p = 0.007) in patients after pulmonary resection.

CONCLUSIONS

Digital chest drainage system is expected to benefit patients to attain faster recovery and higher life quality as well as to reduce the risk of postoperative complications. Further RCTs with larger sample size are still needed to more clearly elucidate the advantages of digital chest drainage system.

The Effect of Chronic Consumption of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Antagonists on Blood Pressure and Inotrope Consumption After Separation from Cardiopulmonary Bypass

Background

Chronic use of renin-angiotensin system (RAS) antagonists (angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor antagonists (ARAS)) can cause hypotension during anesthesia. In some studies hemodynamic instability, including hypotension and its effects on the clinical outcome in patients treated with these drugs during coronary artery bypass graft (CABG) and need to excessive vasoactive drugs in these patient population, has been described. The aim of this study was to evaluate the effect of chronic consumption of ACEIs and ARAS on blood pressure and inotrope consumption during coronary artery bypass graft under cardiopulmonary bypass.

Methods

A total of 200 patients undergoing coronary artery bypass graft surgery, who were treated with either ARAS or ACEIs (n = 100) over at least 2 months, or who were not treated with any RAS antagonists (control group, n = 100) were enrolled. The mean arterial blood pressure, central venous pressure, and need for vasoactive drugs, were measured after induction of anesthesia (T1) before cardiopulmonary bypass (T2) and after separation from (CPB), (T3).

Results

There were no significant differences regarding the mean arterial pressure (case group: T1: 84 ± 7 mmHg, T2: 77 ± 6 mmHg, T3: 83 ± 8 mmHg), (control group: T1: 85 ± 7 mmHg, T2: 81 ± 7 mmHg, T3:84 ± 6 mmHg) between two groups (P > 0.05). Also there were no significant differences regarding mean central venous pressure, mean heart rate, and vasoactive drug consumption between the two groups during the time of intervals.

Conclusions

We found that preoperative (RAS) antagonist’s continuation have not profound hemodynamic changes during coronary artery bypass graft under cardiopulmonary bypass and so we conclude that omitting these drugs before surgery did not have a sufficient advantage to be recommended routinely.

Assessment of the Risk Factors and Outcomes for Postoperative Atrial Fibrillation Patients Undergoing Isolated Coronary Artery Bypass Grafting

BACKGROUND

Atrial fibrillation is the most common complication of cardiac surgery and is associated with significant morbidity and mortality. Recognizing patients at high risk for developing postoperative atrial fibrillation (POAF) may help identify those who could benefit from strategies to prevent POAF. This study was conducted to delineate outcomes and to assess risk factors for POAF among Taiwanese patients undergoing coronary artery bypass grafting (CABG).

METHODS

From January 2009 until February 2012, this prospective study included 266 consecutive patients admitted to our hospital with coronary artery disease. All patients underwent isolated CABG. Patients with preoperative permanent atrial fibrillation and concomitant surgery were excluded. Multiple risk factors associated with the incidence of POAF were collected and evaluated.

RESULTS

POAF occurred in 126 of 226 patients (47.37%). Univariate analysis revealed that significant risk factors for the condition were age, gender, diabetes, dyslipidemia, smoking, impaired renal function, impaired cardiac function, and increased serum electrolytes. Multivariate analysis showed dyslipidemia [hazard ratio (HR): 0.418; 95% confidence interval (Cl): 0.190-0.915, p = 0.029], impaired renal function as indicated by an estimated glomerular filtration rate < 60 mL/min/1.73 m(2) (HR: 3.174; 95% CI: 1.432-7.037, p = 0.004), and serum sodium (HR: 1.112; 95% Cl: 1.047-1.182, p = 0.001) prior to cardiopulmonary bypass as significant. Moreover, POAF was associated with lower 30-day, 1- and 3-year cumulative survival rates and higher early postoperative complications.

CONCLUSIONS

Patients with isolated CABG who were administered β-blockers, angiotensin converting enzyme inhibitor/angiotensin receptor blockers treatment, and lipid therapy before CABG were associated with reduced POAF, while those with impaired renal function and higher serum sodium before CABG predisposed POAF in a Taiwanese population.

KEY WORDS

Atrial fibrillation (AF); Coronary artery bypass grafting (CABG); Coronary artery disease (CAD); Postoperative atrial fibrillation (POAF).