Angiotensin Receptor Blockade Improves Cardiac Surgical Outcomes in Patients With Metabolic Syndrome

Perioperative use of angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEis) in patients undergoing cardiac operations remains controversial. The current practice of discontinuing renin-angiotensin-system inhibitors preoperatively may negate their beneficial effects in vulnerable populations, including patients with metabolic syndrome, who exhibit elevated renin-angiotensin system activity. We hypothesized that preoperative ARB use is associated with reduced incidence of postoperative complications, compared with ACEi or no drug, in patients with metabolic syndrome undergoing coronary artery bypass grafting.

We used propensity matching to derive a cohort of 1,351 patients from 2,998 who underwent coronary artery bypass grafting based on preoperative use of ARBs, ACEis, or no renin-angiotensin-system inhibitors. Our primary end point was a composite of adverse events occurring within 30 days after the operation: new-onset atrial fibrillation/flutter, arrhythmia requiring cardioversion, perioperative myocardial infarction, acute renal failure, need for dialysis, cerebrovascular accidents, acute respiratory failure, or perioperative death.

At least one adverse event occurred in 524 (38.8%) of matched cohort patients (1,184 [39.6% of all patients]). Adjusting for European System for Cardiac Operative Risk Evaluation and metabolic syndrome in the matched cohort, preoperative use of ARBs was associated with a lower incidence of adverse events in patients with metabolic syndrome compared with preoperative use of no renin-angiotensin-system inhibitors (odds ratio, 0.43; 95% confidence interval, 0.19 to 0.99) or ACEis (odds ratio, 0.38; 95% confidence interval, 0.16 to 0.88).

Preoperative use of ARBs, but not ACEis, confers a benefit within 30 days after cardiac operations in patients with metabolic syndrome, suggesting potential efficacy differences of these drug classes in reducing cardiovascular morbidity and death in ambulatory vs surgical patients.