The clinical outcomes of varying perioperative holding time of renin angiotensin aldosterone system inhibitors in patients undergoing coronary artery bypass grafting: a retrospective real-world study
Z Alhaddad, A Alamer, S Almarzook, M Alomer, H Alaqel, A Alabdulhadi, Y AlsaffarAbstract
Introduction
The optimal perioperative management of renin-angiotensin-aldosterone system (RAAS) inhibitors in patients undergoing coronary artery bypass graft (CABG) surgery remains uncertain. Continuation may cause intraoperative hypotension and vasoplegia, while withholding them may result in perioperative hypertension. Thus, the ideal preoperative holding interval is not well established.
Purpose
Evaluate the impact of different preoperative holding intervals of RAAS inhibitors on the clinical outcomes of patients undergoing CABG surgery.
Methodology
This retrospective cohort study portrays real-world evidence and was conducted at a tertiary hospital and including adults(≥18 years) who underwent CABG, were controlled preoperatively on RAAS inhibitors, and admitted between the 24th of February 2024 to December 2024. The primary endpoints consisted of the incidence of intraoperative hypotension (MAP<65mmHg), vasoplegia, requirement of high doses of vasoactive agents, and prolonged infusion of vasoactive agents for more than 6 hr post-cardiopulmonary bypass. Proportional odds and logistic regression Bayesian models were used to analyze outcomes.
Result
A total of 130 patients were included in the study, with a median age of 55 years (interquartile range: 48.3–62), and 15.4% were female. More than half of the cohort (52%) were receiving angiotensin-converting enzyme inhibitors (ACEIs), 36.2% were receiving angiotensin receptor blockers (ARBs), and 11.5% were on sacubitril/valsartan. The preoperative holding times for RAAS inhibitors were <24h (n=38), 24–36h (n=64), and >36h (n=28). Intraoperative hypotension (MAP <65 mmHg) occurred in 6 patients (4.6%), with no significant differences between groups, as demonstrated by probabilities from the Bayesian proportional odds model: 3.9% (95% CrI 1.12%–7.3%) in the <24h group, 3.0% (95% CrI 1.1%–5.4%) in the 24–36h group, and 4.7% (95% CrI 1.1%–8.9%) in the >36h group. Only one patient (0.8%) developed vasoplegia. Compared with the <24h group, the requirement for high-dose inotropes was lower in the 24–36h group (OR 0.33, 95% CrI 0.11–1.06; probability OR<1 = 97%) and in the >36h group (OR 0.68, 95% CrI 0.19–2.33; probability OR<1 = 73%). Compared with the <24h group, the duration of inotrope infusion was shorter in the 24–36h group (OR 0.58, 95% CrI 0.26–1.4; probability OR<1 = 90%) and longer in the >36h group (OR 1.9, 95% CrI 0.65–5.21; probability OR>1 = 86%).
Conclusions
This observational study showed that withholding RAAS inhibitors for 24–36 hr before CABG was associated with higher postoperative MAP, and much lower inotrope requirements, and shorter duration of inotropes infusion time. These findings suggest that a 24–36 h holding period may represent as the safest perioperative strategy for patients undergoing CABG surgery.