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ACEI BEFORE CABG: EFFECTS ON HEMODYNAMY AND RENAL FUNCTION

Département d’anesthésiologie, Hôpital Laval, 2725 chemin Ste-Foy, Ste-Foy, G1V 4G5.

INTRODUCTION

Angiotensin converting enzyme inhibitors (ACEI) cause intraoperative hemodynamic instability (IOHI) during CABG (1). They are associated with postoperative renal dysfunction (PORD) in vascular surgery (2). Omitting ACEI on the day of surgery (DOS) seems to improve hemodynamic stability during vascular surgery (3). This retrospective study was designed to assess if chronic ACEI treatment or ACEI omission on DOS influence the incidence of IOHI and PORD during CABG.

METHOD

We evaluated the incidence of IOHI, the use of vasopressive drugs, and the incidence of PORD which was defined as an increase of creatinine>50µmol/L or an increase of creatinine>25% or a decrease of creatinine clearance>25% from preoperative values at POD-2 and discharge. We realized multivariate analyses controlled for factors known to influence PORD.

RESULTS

1228 patients have undergone CABG in 2002; 50% were on chronic ACEI and 75% of them omitted it on DOS. In the ACEI group patients, there were more frequent IOHI (MAP< 40 mmHG (2.42% vs 0.66%; p=0.0274)) and an increase use of vasopressive drugs (17.4% vs 8.7%; p=0.0410) during CPB compared with patients on other cardiovascular medications. No difference in PORD was found. Finally, no significant difference was observed whether the ACEI was continued or not on DOS.

DISCUSSION

More IOHI were found in patients treated with chronic ACEI but there were no difference whether the ACEI was omitted or administered on DOS. Also, chronic ACEI did not increase the incidence of PORD. Our results are reassuring if we consider the benefits of being on ACEI therapy when undergoing CABG (4,5). We hypothese that the delay between the cessation of ACEI and CABG (< 24 hours) might be too short to induce a significant difference, because of the long pharmacologic half time of the ACEI molecules. A prospective study with ACEI omitted 3 or 4 days before CABG instead of on DOS maybe useful to corroborate these results.

REFERENCES

1 CAJ, no 47, p. 433–440.

2 Anesth Analg, no 93, p. 1111–5.

3 Anesthesiology, no 81, p. 299–307.

4 Circulation, no 108, p. 3079–3083.

5 Can J Cardiol, no 18, p. 1192–1200.

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