Patterns of Use of Perioperative ACE Inhibitors in CABG Surgery with Cardiopulmonary Bypass: Effects on In-Hospital Morbidity and Mortality

Background —Despite proven benefit in ambulatory patients with ischemic heart disease, the pattern of use of ACE inhibitors (ACEI) in coronary artery bypass graft (CABG) surgery has been erratic and controversial. Methods and Results —This is a prospective observational study of 4224 patients undergoing CABG surgery. The cohort included 1838 patients receiving ACEI therapy prior to surgery and 2386 (56.5%) without ACEI exposure. Postoperatively, the pattern of ACEI use yielded four groups: Continuation 915 (21.7%); Withdrawal 923 (21.8%); Addition 343 (8.1%); and No-ACEI 2043 (48.4%). Continuous treatment with ACEI vs. no-ACEI was associated with substantive reductions of risk of non-fatal events (adjusted odds ratio (OR) for the composite outcome: (0.69[0.52-0.91]; p=0.009) and cardiovascular event (0.64[0.46-0.88]; p=0.006). Addition of ACEI de novo postoperatively compared to no-ACEI therapy was also associated with a significant reduction of risk in composite outcome (0.56[0.38-0.84]; p=0.004) and cardiovascular event (0.63[0.40-0.97]; p=0.04). On the other hand, continuous treatment of ACEI vs. withdrawal of ACEI was associated with decreased risk of the composite outcome (0.50[0.38-0.66]); p<0.001] as well as decrease in cardiac and renal events (p < 0.001 and p = 0.005, respectively). No differences in in-hospital mortality and cerebral event were noted. Conclusions —Our study suggests that withdrawal of ACEI treatment after CABG surgery is associated with non-fatal in-hospital ischemic events. Further, continuation of ACEI or de novo ACEI therapy early after cardiac surgery is associated with improved in-hospital outcomes.