Rosenman David J, McDonald Furman S, Ebbert Jon O, Erwin Patricia J, LaBella Matthew, Montori Victor M
Knowledge and Encounter Research Unit, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
J Hosp Med. 2008 Jul;3(4):319-25. doi: 10.1002/jhm.323.
Hospitalists involved in perioperative care either stop or continue until the day of surgery renin-angiotensin-aldosterone system antagonists (either angiotensin-converting enzyme inhibitors [ACEI] or angiotensin II receptor subtype 1 antagonists [ARA]) in patients who use these agents chronically. This practice variation reflects uncertainty regarding the risks and benefits of either approach.
The purpose of this study was to assess the clinical consequences of preoperatively continuing versus withholding ACEI/ARAs in patients treated chronically with these agents.
We comprehensively searched 7 major electronic databases, considered references from selected reviews, hand-searched journals, and communicated with experts. We included randomized trials and observational studies.
We evaluated the relative risk (RR) of hypotension requiring vasopressors and of myocardial infarction in patients who did or did not receive an immediate preoperative dose of ACEI or ARA.
Random-effects meta-analysis from 5 studies totaling 434 patients suggested that patients receiving an immediate preoperative ACEI/ARA dose were more likely (RR 1.50, 95% CI 1.15-1.96) to develop hypotension requiring vasopressors at or shortly after induction of anesthesia. Sufficient data were not available to assess other outcomes.
Preoperative administration of ACEI/ARAs increases intraoperative hypotension. The long-term clinical consequences of continuing versus withholding preoperative ACEI/ARAs are unknown. This uncertainty stems in part from the absence to date of randomized trials designed specifically to examine patient-important consequences of this decision.
参与围手术期护理的住院医师对于长期使用肾素-血管紧张素-醛固酮系统拮抗剂（血管紧张素转换酶抑制剂[ACEI]或血管紧张素II 1型受体拮抗剂[ARA]）的患者，要么在手术当天停用这些药物，要么持续使用。这种做法的差异反映了对于这两种方法的风险和益处存在不确定性。
本研究的目的是评估在长期使用这些药物治疗的患者中，术前继续使用与停用ACEI/ARA的临床后果。
我们全面检索了7个主要电子数据库，参考了选定综述中的参考文献，手工检索了期刊，并与专家进行了交流。我们纳入了随机试验和观察性研究。
我们评估了接受或未接受术前即刻剂量ACEI或ARA的患者发生需要血管升压药治疗的低血压和心肌梗死的相对风险（RR）。
来自5项共434例患者的研究的随机效应荟萃分析表明，接受术前即刻剂量ACEI/ARA的患者在麻醉诱导时或诱导后不久更有可能（RR 1.50，95%CI 1.15 - 1.96）发生需要血管升压药治疗的低血压。没有足够的数据来评估其他结局。
术前给予ACEI/ARA会增加术中低血压。术前继续使用与停用ACEI/ARA的长期临床后果尚不清楚。这种不确定性部分源于迄今为止缺乏专门设计用于研究这一决策对患者重要后果的随机试验。
