Department of Anesthesiology, School of Anesthesiology, The First Hospital, Shanxi Medical University, Taiyuan, China.
Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
Ann Surg. 2023 Apr 1;277(4):e948-e954. doi: 10.1097/SLA.0000000000005408. Epub 2022 Feb 15.
The aim of this study was to study the association of perioperative administration of renin angiotensin system inhibitors (RASi) and clinical outcomes of patients with heart failure (HF) undergoing cardiac surgery.
It is controversial whether the perioperative RASi should be administered in HF patients undergoing cardiac surgery.
A total of 2338 patients with HF and undergoing CABG and/or valve surgeries at multiple hospitals from 2001 to 2015 were identified from STS database. After adjustment using propensity score and instrumental variable, logistic regression was conducted to analyze the influence of preoperative continuation of RASi (PreRASi) on short-term in-hospital outcomes. Independent risk factors of 30-day mortality, major adverse cardiovascular events (MACE), and renal failure were analyzed by use of stepwise logistic regression. The effects of pre- and postoperative use of RASi (PostRASi) on long-term mortality were analyzed using survival analyses. Stepwise Cox regression was conducted to analyze the independent risk factors of 6-year mortality. The relationships of HF status and surgery type with perioperative RASi, as well as PreRASi-PostRASi, were also evaluated by subgroup analyses.
PreRASi was associated with lower incidences of 30-day mortality [ P < 0.0001, odds ratio (OR): 0.556, 95% confidence interval (CI) 0.405-0.763], stroke ( P =0.035, OR: 0.585, 95% CI: 0.355-0.962), renal failure ( P =0.007, OR: 0.663, 95% CI: 0.493-0.894). Both PreRASi ( P =0.0137) and PostRASi ( P =0.007) reduced 6-year mortality compared with the No-RASi groups.
Pre- and postoperative use of RASi was associated with better outcomes for the patients who have HF and undergo CABG and/or valve surgeries. Preoperative continuation and postoperative restoration are warranted in these patients.
本研究旨在探讨心脏手术围手术期肾素血管紧张素系统抑制剂（RASi）的应用与心力衰竭（HF）患者临床结局的关系。
HF 患者心脏手术后是否应给予围手术期 RASi 治疗尚存争议。
从 STS 数据库中确定了 2001 年至 2015 年期间在多家医院接受 CABG 和/或瓣膜手术的 2338 例 HF 患者。通过倾向评分和工具变量调整后，采用 logistic 回归分析术前继续使用 RASi（PreRASi）对短期院内结局的影响。采用逐步 logistic 回归分析 30 天死亡率、主要心血管不良事件（MACE）和肾功能衰竭的独立危险因素。采用生存分析评估术前和术后使用 RASi（PostRASi）对长期死亡率的影响。采用逐步 Cox 回归分析 6 年死亡率的独立危险因素。通过亚组分析评估 HF 状态和手术类型与围手术期 RASi 以及 PreRASi-PostRASi 的关系。
PreRASi 与 30 天死亡率降低相关[ P < 0.0001，比值比（OR）：0.556，95%置信区间（CI）：0.405-0.763]、卒中（ P =0.035，OR：0.585，95%CI：0.355-0.962）、肾功能衰竭（ P =0.007，OR：0.663，95%CI：0.493-0.894）。与 No-RASi 组相比，PreRASi（ P =0.0137）和 PostRASi（ P =0.007）均降低了 6 年死亡率。
HF 患者行 CABG 和/或瓣膜手术时，术前和术后使用 RASi 可改善患者的预后。这些患者需要术前继续使用并术后恢复使用 RASi。
