Meta-Analysis
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Apr 26, 2022; 14(4): 250-259
Published online Apr 26, 2022. doi: 10.4330/wjc.v14.i4.250
Effect of preoperative renin-angiotensin system blockade on vasoplegia after cardiac surgery: A systematic review with meta-analysis
Jean Jacques Noubiap, Brice Nouthe, Ying Tung Sia, Marco Spaziano
Jean Jacques Noubiap, Centre for Heart Rhythm Disorders, The University of Adelaide, Adelaide 5000, South Australia, Australia
Brice Nouthe, Department of Medicine, University of British Columbia, Vancouver V6T 1W5, Canada
Ying Tung Sia, Department of Medicine, Regional Trois-Rivières Hospital (CIUSSS-MCQ), Trois-Rivières 5000, Canada
Marco Spaziano, Department of Cardiology, McGill University Health Centre, Montréal QC H4A 3J1, Canada
Author contributions: Nouthe B, Noubiap JJ, Spaziano M and Sia YT contributed to the conception and design; Nouthe B, Noubiap JJ, and Spaziano M contributed to the search strategy; Nouthe B and Noubiap JJ contributed to the studies selection, data analysis and synthesis, data interpretation; Noubiap JJ contributed to the manuscript drafting; Nouthe B, Noubiap JJ, Spaziano M and Sia YT contributed to the manuscript revision, and approval of the final manuscript.
Conflict-of-interest statement: All authors report no disclosures.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Jean Jacques Noubiap, MD, MMed, Academic Research, Senior Editor, Statistician, Centre for Heart Rhythm Disorders, The University of Adelaide, Port Road, Adelaide 5000, South Australia, Australia. noubiapjj@yahoo.fr
Received: December 5, 2021
Peer-review started: December 5, 2021
First decision: January 25, 2022
Revised: February 9, 2022
Accepted: March 27, 2022
Article in press: March 27, 2022
Published online: April 26, 2022
Abstract
BACKGROUND

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.

AIM

To update and summarize data on the effect of preoperative use of RAS blockers on incident vasoplegia.

METHODS

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.

RESULTS

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; I2 49%) but not increased by the use of beta blockers (pooled aOR 0.78, 95%CI: 0.36-1.69; I2 77%). Two randomized control trials (RCTs), not eligible for the meta-analysis, did not show an association between continuation of RAS blockers and vasoplegia.

CONCLUSION

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.

Keywords: Vasoplegia, Cardiac surgery, Coronary artery bypass graft, Angiotensin converting enzyme inhibitors

Core Tip: Vasoplegia is a common complication of cardiac surgery but its causal relationship with preoperative use of renin angiotensin system blockers, mainly angiotensin converting enzyme inhibitors (ACEIs), is still debated. The meta-analysis of observational studies suggests that preoperative continuation of ACEIs is associated with an increased risk of vasoplegia and of the use of inotropic support postoperatively. However, these associations were not observed in two included randomized controlled trials with limited power. These findings support the potential benefit of holding ACEIs prior to cardiac surgery to reduce the risk of vasoplegia and associated adverse outcomes. However, well-powered randomized controlled trials using a consensus definition of vasoplegia are still needed to properly assess management strategies of RAS blockers in the perioperative setting.