Tolerance to ACE inhibitors after cardiac surgery

Area of Science:

• Cardiology
• Pharmacology
• Nephrology

Background:

• Angiotensin-converting enzyme (ACE) inhibitors offer benefits in heart failure but can cause first-dose hypotension, especially post-coronary artery bypass grafting (CABG).
• Early post-operative ACE inhibitor initiation in CABG patients with impaired renal and ventricular function requires careful hemodynamic assessment.

Purpose of the Study:

• To evaluate the hemodynamic tolerance of early post-operative perindopril and enalapril in CABG patients with impaired renal and ventricular function.
• To compare the safety and efficacy of perindopril versus enalapril in this specific patient cohort.

Main Methods:

• Eighty-one CABG patients with impaired ejection fraction (LVEF) and renal function were randomized to placebo, perindopril, or enalapril.
• Patients were stratified by mild (LVEF 35-65%) and significant (LVEF <35%) ventricular dysfunction.
• Intolerance was defined by hypotension unresponsive to furosemide, necessitating treatment discontinuation or dopamine initiation.

Main Results:

• In patients with mild ventricular dysfunction, perindopril discontinuation occurred in 1/20 and enalapril in 4/20 (not significant).
• In patients with significant ventricular dysfunction, perindopril was discontinued in 2/7 and enalapril in all 7/7 patients (P=0.02).

Conclusions:

• Early post-operative ACE inhibitor use is poorly tolerated in CABG patients with impaired renal function and significant ventricular dysfunction.
• Perindopril demonstrated superior hemodynamic tolerance compared to enalapril in this high-risk group, suggesting potential advantages.