Discontinuation vs. continuation of renin-angiotensin system inhibition before non-cardiac surgery : the SPACE trial
© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology..
BACKGROUND AND AIMS: Haemodynamic instability is associated with peri-operative myocardial injury, particularly in patients receiving renin-angiotensin system (RAS) inhibitors (angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers). Whether stopping RAS inhibitors to minimise hypotension, or continuing RAS inhibitors to avoid hypertension, reduces peri-operative myocardial injury remains unclear.
METHODS: From 31 July 2017 to 1 October 2021, patients aged ≥60 years undergoing elective non-cardiac surgery were randomly assigned to either discontinue or continue RAS inhibitors prescribed for existing medical conditions in six UK centres. Renin-angiotensin system inhibitors were withheld for different durations (2-3 days) before surgery, according to their pharmacokinetic profile. The primary outcome, masked to investigators, clinicians, and patients, was 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.
RESULTS: Two hundred and sixty-two participants were randomized to continue (n = 132) or stop (n = 130) RAS inhibitors. Myocardial injury occurred in 58 (48.3%) patients randomized to discontinue, compared with 50 (41.3%) patients who continued, RAS inhibitors [odds ratio (for continuing): 0.77; 95% confidence interval (CI) 0.45-1.31]. Hypertensive adverse events were more frequent when RAS inhibitors were stopped [16 (12.4%)], compared with 7 (5.3%) who continued RAS inhibitors [odds ratio (for continuing): 0.4; 95% CI 0.16-1.00]. Hypotension rates were similar when RAS inhibitors were stopped [12 (9.3%)] or continued [11 (8.4%)].
CONCLUSIONS: Discontinuing RAS inhibitors before non-cardiac surgery did not reduce myocardial injury, and could increase the risk of clinically significant acute hypertension. These findings require confirmation in future studies.
| Medienart: |
E-Artikel |
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| Erscheinungsjahr: |
2024 |
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| Erschienen: |
2024 |
| Enthalten in: |
Zur Gesamtaufnahme - volume:45 |
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| Enthalten in: |
European heart journal - 45(2024), 13 vom: 01. Apr., Seite 1146-1155 |
| Sprache: |
Englisch |
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| Beteiligte Personen: |
Ackland, Gareth L [VerfasserIn] |
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| Links: |
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| Anmerkungen: |
Date Completed 03.04.2024 Date Revised 03.04.2024 published: Print Citation Status MEDLINE |
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| doi: |
10.1093/eurheartj/ehad716 |
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| funding: |
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| Förderinstitution / Projekttitel: |
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| 100 | 1 | |a Ackland, Gareth L |e verfasserin |4 aut | |
| 245 | 1 | 0 | |a Discontinuation vs. continuation of renin-angiotensin system inhibition before non-cardiac surgery |b the SPACE trial |
| 264 | 1 | |c 2024 | |
| 336 | |a Text |b txt |2 rdacontent | ||
| 337 | |a ƒaComputermedien |b c |2 rdamedia | ||
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| 500 | |a Date Completed 03.04.2024 | ||
| 500 | |a Date Revised 03.04.2024 | ||
| 500 | |a published: Print | ||
| 500 | |a Citation Status MEDLINE | ||
| 520 | |a © The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. | ||
| 520 | |a BACKGROUND AND AIMS: Haemodynamic instability is associated with peri-operative myocardial injury, particularly in patients receiving renin-angiotensin system (RAS) inhibitors (angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers). Whether stopping RAS inhibitors to minimise hypotension, or continuing RAS inhibitors to avoid hypertension, reduces peri-operative myocardial injury remains unclear | ||
| 520 | |a METHODS: From 31 July 2017 to 1 October 2021, patients aged ≥60 years undergoing elective non-cardiac surgery were randomly assigned to either discontinue or continue RAS inhibitors prescribed for existing medical conditions in six UK centres. Renin-angiotensin system inhibitors were withheld for different durations (2-3 days) before surgery, according to their pharmacokinetic profile. The primary outcome, masked to investigators, clinicians, and patients, was 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 | ||
| 520 | |a RESULTS: Two hundred and sixty-two participants were randomized to continue (n = 132) or stop (n = 130) RAS inhibitors. Myocardial injury occurred in 58 (48.3%) patients randomized to discontinue, compared with 50 (41.3%) patients who continued, RAS inhibitors [odds ratio (for continuing): 0.77; 95% confidence interval (CI) 0.45-1.31]. Hypertensive adverse events were more frequent when RAS inhibitors were stopped [16 (12.4%)], compared with 7 (5.3%) who continued RAS inhibitors [odds ratio (for continuing): 0.4; 95% CI 0.16-1.00]. Hypotension rates were similar when RAS inhibitors were stopped [12 (9.3%)] or continued [11 (8.4%)] | ||
| 520 | |a CONCLUSIONS: Discontinuing RAS inhibitors before non-cardiac surgery did not reduce myocardial injury, and could increase the risk of clinically significant acute hypertension. These findings require confirmation in future studies | ||
| 650 | 4 | |a Randomized Controlled Trial | |
| 650 | 4 | |a Journal Article | |
| 650 | 4 | |a Major cardiac events | |
| 650 | 4 | |a Myocardial injury | |
| 650 | 4 | |a Non-cardiac surgery | |
| 650 | 4 | |a Peri-operative care | |
| 650 | 4 | |a Renin–angiotensin system inhibitors | |
| 650 | 7 | |a Angiotensin-Converting Enzyme Inhibitors |2 NLM | |
| 650 | 7 | |a Antihypertensive Agents |2 NLM | |
| 650 | 7 | |a Angiotensin Receptor Antagonists |2 NLM | |
| 700 | 1 | |a Patel, Akshaykumar |e verfasserin |4 aut | |
| 700 | 1 | |a Abbott, Tom E F |e verfasserin |4 aut | |
| 700 | 1 | |a Begum, Salma |e verfasserin |4 aut | |
| 700 | 1 | |a Dias, Priyanthi |e verfasserin |4 aut | |
| 700 | 1 | |a Crane, David R |e verfasserin |4 aut | |
| 700 | 1 | |a Somanath, Sameer |e verfasserin |4 aut | |
| 700 | 1 | |a Middleditch, Alexander |e verfasserin |4 aut | |
| 700 | 1 | |a Cleland, Stuart |e verfasserin |4 aut | |
| 700 | 1 | |a Gutierrez Del Arroyo, Ana |e verfasserin |4 aut | |
| 700 | 1 | |a Brealey, David |e verfasserin |4 aut | |
| 700 | 1 | |a Pearse, Rupert M |e verfasserin |4 aut | |
| 700 | 0 | |a Stopping Perioperative ACE-inhibitors or angiotensin-II receptor blockers (SPACE) trial investigators |e verfasserin |4 aut | |
| 700 | 1 | |a Ackland, Gareth |e investigator |4 oth | |
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