It has been debated whether ACEIs should be discontinued before CABG [136, 137, 140]. The Ischemia Management With Accupril Post Bypass Graft Via Inhibition of the coNverting Enzyme (IMAGINE) study did not show any benefit of quinapril compared to placebo initiated early within 7 days of surgery; greater rates of morbidity and mortality have been observed at 3 months in the quinapril group [141]. However, the exact timing of the discontinuation and reinstitution of these drugs is poorly defined [138, 141]. RAAS inhibitors, including the ARBs and ACEIs, can also increase the risk for perioperative hypotension [142] and vasodilatory shock [143], causing decreased systemic vascular resistance [138]. Therefore, the use of inotropes and vasopressors is increased, and the time patients spend on ventilators and in the intensive care unit (ICU) is extended [137, 144]. For these reasons, there is a consensus on discontinuing RAAS blockers before cardiac surgery (Table 6) [136, 137, 140]. In patients with preoperatively uncontrolled hypertension, long-acting ACEIs and ARBs may be switched to short-acting ACEIs. Additionally, patients treated with sacubitril/valsartan should have the same preoperative assessment as other patients treated with RAAS inhibitors. There are currently no data on whether aldosterone receptor antagonists should be stopped or continued until surgery.
Different types of renin–angiotensin–aldosterone system inhibitors
 |
|
Including the half-life of its pharmacologically active metabolite.
ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin II receptor blocker.
Different types of renin–angiotensin–aldosterone system inhibitors
|
|
Including the half-life of its pharmacologically active metabolite.
ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin II receptor blocker.
