Noubiap Jean Jacques, Nouthe Brice, Sia Ying Tung, Spaziano Marco
Centre for Heart Rhythm Disorders, The University of Adelaide, Adelaide 5000, South Australia, Australia.
Department of Medicine, University of British Columbia, Vancouver V6T 1W5, Canada.
World J Cardiol. 2022 Apr 26;14(4):250-259. doi: 10.4330/wjc.v14.i4.250.
Vasoplegia is a common complication of cardiac surgery but its causal relationship with preoperative use of renin angiotensin system (RAS) blockers [angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARB)] is still debated.
To update and summarize data on the effect of preoperative use of RAS blockers on incident vasoplegia.
All published studies from MEDLINE, EMBASE, and Web of Science providing relevant data through January 13, 2021 were identified. A random-effects meta-analysis method was used to pool estimates, and post-cardiac surgery shock was differentiated from vasoplegia.
Ten studies reporting on a pooled population of 15672 patients (none looking at ARBs exclusively) were included in the meta-analysis. All were case-control studies. Use of ACEIs was associated with an increased risk of vasoplegia [pooled adjusted odds ratio (Aor) of 2.06, 95%CI: 1.45-2.93] and increased inotropic/vasopressor support requirement (pooled aOR 1.19, 95%CI: 1.10-1.29). Post-cardiac surgery shock was increased in the presence of left ventricular dysfunction (pooled aOR 2.32, 95%CI: 1.60-3.36; 49%) but not increased by the use of beta blockers (pooled aOR 0.78, 95%CI: 0.36-1.69; 77%). Two randomized control trials (RCTs), not eligible for the meta-analysis, did not show an association between continuation of RAS blockers and vasoplegia.
Preoperative continuation of ACEIs is associated with an increased need for inotropic support postoperatively and with an increased risk of vasoplegia in observational studies but not in RCTs. The absence of a consensus definition of vasoplegia should lead to the use of perioperative cardiovascular monitoring when designing RCTs to better understand this discrepancy.
血管麻痹是心脏手术常见的并发症，但其与术前使用肾素 - 血管紧张素系统（RAS）阻滞剂[血管紧张素转换酶抑制剂（ACEI）和血管紧张素受体阻滞剂（ARB）]之间的因果关系仍存在争议。
更新并总结术前使用RAS阻滞剂对血管麻痹发生率影响的数据。
检索MEDLINE、EMBASE和Web of Science截至2021年1月13日发表的所有提供相关数据的研究。采用随机效应荟萃分析方法汇总估计值，并区分心脏手术后休克和血管麻痹。
荟萃分析纳入了10项研究，共15672例患者（均非仅观察ARB）。所有研究均为病例对照研究。使用ACEI与血管麻痹风险增加相关[合并调整优势比（Aor）为2.06，95%CI：1.45 - 2.93]，且增加了对正性肌力药/血管升压药支持的需求（合并aOR 1.19，95%CI：1.10 - 1.29）。存在左心室功能障碍时，心脏手术后休克增加（合并aOR 2.32，95%CI：1.60 - 3.36；P = 49%），但使用β受体阻滞剂未使其增加（合并aOR 0.78，95%CI：0.36 - 1.69；P = 77%）。两项不符合荟萃分析纳入标准的随机对照试验（RCT）未显示继续使用RAS阻滞剂与血管麻痹之间存在关联。
在观察性研究中，术前继续使用ACEI与术后对正性肌力支持的需求增加以及血管麻痹风险增加相关，但在RCT中并非如此。血管麻痹缺乏共识定义，这应促使在设计RCT时使用围手术期心血管监测，以更好地理解这种差异。
