评估继续停用肾素-血管紧张素系统抑制剂的风险和益处：一项采用序贯试验分析的系统评价和荟萃分析

Evaluating the risks and benefits of continuing withholding renin-angiotensin system inhibitors: a systematic review and meta-analysis with trial sequential analysis.

作者信息

Shalabi Laila, Ibrahim Ahmed, Zreigh Sofian, Rifai Mohamed, Ramadan Shrouk, Arafa Mohamed A, Mustafa Osama M, Ansab Muhammad, Krayem Mohamed F, Elsabbagh Ibrahim, Mash'al Nour H, Waleed Salem, Legrand Matthieu

机构信息

Faculty of Medicine, Gharyan University, Gharyan, Libya.

Faculty of Medicine, Alexandria University, Alexandria, Egypt.

出版信息

BJA Open. 2025 May 3;14:100405. doi: 10.1016/j.bjao.2025.100405. eCollection 2025 Jun.

DOI:10.1016/j.bjao.2025.100405

PMID:40421444

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC12104715/

Abstract

BACKGROUND

The best perioperative management of renin-angiotensin system inhibitors (RASi) in patients undergoing noncardiac surgery has been an ongoing debate as a result of inconclusive previous studies and insufficient data for robust guidelines. Although continuation of RASi may lead to intraoperative hypotension, withholding might also cause postoperative complications. Our meta-analysis aims to explore the postoperative outcomes of strategies of RASi management before surgery by evaluating randomised clinical trials, to provide more definitive conclusions for clinical practice.

METHODS

We systematically searched PubMed, Scopus, Cochrane, and Web of Science until September 2024. Inclusion criteria included patients (≥18 yr) who underwent noncardiac surgery and received long-term RASi, which were either withheld or continued before surgery. Statistical analysis was conducted using R Studio version 4.4.2.

RESULTS

A total of seven RCTs with 8741 patients receiving long-term RASi before noncardiac surgery revealed no significant difference between continuation and withholding groups regarding cardiovascular complications (risk ratio [RR] 0.94, 95% confidence interval [CI] 0.80-1.09, =0.41), mortality (RR 1.16, 95% CI 0.55-2.43, =0.71), and acute kidney injury (RR 0.95, 95% CI 0.84-1.06, =0.33). However, continuation of RASi was associated with a higher incidence of intraoperative hypotension (RR 1.33, 95% CI 1.23-1.44, <0.001). Additionally, the incidence of postoperative severe hypertension (systolic BP >180 mm Hg) was significantly lower in the continuation group (RR 0.63, 95% CI 0.40-0.98, <0.002).

CONCLUSIONS

Continuing RASi before noncardiac surgery does not significantly impact mortality, cardiovascular complications or the risk of acute kidney injury. However, continuation is associated with an increased risk of intraoperative hypotension, and withholding with a higher risk of postoperative severe hypertension.

SYSTEMATIC REVIEW PROTOCOL

CRD42024605208 (PROSPERO).

摘要

背景

由于既往研究结果不明确且缺乏足够数据来制定强有力的指南，对于接受非心脏手术患者围手术期肾素 - 血管紧张素系统抑制剂（RASi）的最佳管理方案一直存在争议。尽管继续使用RASi可能导致术中低血压，但停用也可能引起术后并发症。我们的荟萃分析旨在通过评估随机临床试验来探讨术前RASi管理策略的术后结局，为临床实践提供更明确的结论。

方法

我们系统检索了截至2024年9月的PubMed、Scopus、Cochrane和Web of Science。纳入标准包括接受非心脏手术且长期使用RASi的患者（≥18岁），这些患者在术前停用或继续使用RASi。使用R Studio 4.4.2版本进行统计分析。

结果

共有7项随机对照试验，涉及8741例在非心脏手术前接受长期RASi治疗的患者，结果显示继续使用和停用组在心血管并发症（风险比[RR] 0.94，95%置信区间[CI] 0.80 - 1.09，P = 0.41）、死亡率（RR 1.16，95% CI 0.55 - 2.43，P = 0.71）和急性肾损伤（RR 0.95，95% CI 0.84 - 1.06，P = 0.33）方面无显著差异。然而，继续使用RASi与术中低血压发生率较高相关（RR 1.33，95% CI 1.23 - 1.44，P < 0.001）。此外，继续使用组术后严重高血压（收缩压>180 mmHg）的发生率显著较低（RR 0.63，95% CI 0.40 - 0.98，P < 0.002）。