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Cochrane Database of Systematic Reviews

Inhibidores de la enzima convertidora de angiotensina o bloqueadores de los receptores de angiotensina II tipo 1 perioperatorios para la prevención de la mortalidad y la morbilidad en adultos

Información

DOI:
https://doi.org/10.1002/14651858.CD009210.pub2Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 27 enero 2016see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:

  1. Grupo Cochrane de Anestesia

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Contraer

Autores

  • Zui Zoua

    Department of Anaesthesiology, Changzheng Hospital, The Second Military Medical University, Shanghai, China

    Joint first author

  • Hong B Yuana

    Department of Anaesthesiology, Changzheng Hospital, The Second Military Medical University, Shanghai, China

    Joint first author

  • Bo Yanga

    Kidney Institute of CPLA, Division of Nephrology, Changzheng Hospital, Second Military Medical University, Shanghai, China

    Joint first author

  • Fengying Xu

    Department of Anaesthesiology, Changzheng Hospital, The Second Military Medical University, Shanghai, China

  • Xiao Y Chen

    Department of Neurology, The General Hospital of the People's Liberation Army (PLAGH) (also Hospital 301), Beijing, China

  • Guan J Liu

    Cochrane China, West China Hospital, Sichuan University, Chengdu, China

  • Xue Y Shi

    Correspondencia a: Department of Anaesthesiology, Changzheng Hospital, The Second Military Medical University, Shanghai, China

    [email protected]

    Department of Anesthesiology and SICU, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China

Contributions of authors

Zui Zou (ZZ), Hong B Yuan (HBY), Bo Yang (BY), Fengying Xu (FYX), Xiao Y Chen (XYC), Guan J Liu (GJL), Xue Y Shi (XYS)

Joint first authors: Zui Zou, Hong B Yuan, Bo Yang

Conceiving the review: ZZ, XYS

Co‐ordinating the review: ZZ, XYS

Undertaking manual searches: XYC

Screening search results: ZZ, XYC

Organizing retrieval of papers: ZZ, HBY

Screening retrieved papers against inclusion criteria: ZZ

Appraising quality of papers: ZZ, XYS

Abstracting data from papers: ZZ, XYC

Writing to authors of papers for additional information: XYS

Providing additional data about papers: HBY, BY

Obtaining and screening data on unpublished studies: HBY

Data management for the review: ZZ, XYS

Entering data into Review Manager (RevMan 5.3): BY

RevMan statistical data: ZZ, XYS

Other statistical analysis not using RevMan: ZZ, GJL

Double entry of data: ZZ, HBY

Interpretation of data: XYS

Statistical inferences: GJL

Writing the review: ZZ, BY, XYS

Revising the review: FYX, BY

Securing funding for the review: XYS

Performing previous work that was the foundation of the present study: ZZ, XYS

Guarantor for the review (one author): XYS

Person responsible for reading and checking review before submission: ZZ, XYS

Sources of support

Internal sources

  • No sources of support supplied

External sources

  • National Nature Science Foundation of China (81372103), China.

  • Key Program of Medical Science Development of PLA (BWS12J027), China.

  • Program of Shanghai Municipal Health Planning Commission (2013SY025), China.

  • Shanghai Rising‐Star Program (15QA1405000), China.

  • Natural Science Foundation of Shanghai (14ZR1413700), China.

Declarations of interest

See: Sources of support.

Zui Zou: none known

Hong B Yuan: none known

Bo Yang: none known

Fengying Xu: none known

Xiao Y Chen: none known

Guan J Liu: none known

Xue Y Shi: none known

Acknowledgements

We would like to thank Javier Eslava‐Schmalbach (content editor), Nathan Pac (statistical editor), Pierre Foex, Claudio Bravo (peer reviewers), and Patricia Tong (consumer referee) for their help and editorial advice during the preparation of this systematic review.

Version history

Published

Title

Stage

Authors

Version

2016 Jan 27

Perioperative angiotensin‐converting enzyme inhibitors or angiotensin II type 1 receptor blockers for preventing mortality and morbidity in adults

Review

Zui Zou, Hong B Yuan, Bo Yang, Fengying Xu, Xiao Y Chen, Guan J Liu, Xue Y Shi

https://doi.org/10.1002/14651858.CD009210.pub2

2011 Jul 06

Perioperative angiotensin‐converting enzyme inhibitors or angiotensin II type 1 receptor blockers for preventing surgery‐related mortality and morbidity

Protocol

Zui Zou, Hong B Yuan, Xiao Y Chen, Guan J Liu, Xue Y Shi

https://doi.org/10.1002/14651858.CD009210

Differences between protocol and review

  1. Two new authors joined the team: Bo Yang and Fengying Xu.

  2. We changed the original title of the protocol, 'Perioperative angiotensin‐converting enzyme inhibitors or angiotensin II type 1 receptor blockers for preventing surgery‐related mortality and morbidity in adults', to 'Perioperative angiotensin‐converting enzyme inhibitors or angiotensin II type 1 receptor blockers for preventing mortality and morbidity in adults', as suggested by referee Pierre Foex.

  3. We changed the original objectives of the protocol, 'to systematically assess the benefits and harms of administration (prophylaxis or treatment or both) of angiotensin‐converting enzyme inhibitors (ACEIs) and angiotensin II type I receptors blockers (ARBs) in the short‐term perioperative period for the prevention of surgery related mortality and morbidity', to 'to systematically assess the benefits and harms of administration of ACEIs or ARBs perioperatively for the prevention of mortality and morbidity in adults (aged 18 years and above) undergoing any type of surgery under general anaesthesia' to keep coincident with the revised title and ensure the precision of the objectives description.

  4. We rearranged the criteria for considering studies for this review and refined the presentation but did not change the exact meaning.

  5. We added length of hospital stay as a secondary outcome to enrich the results.

  6. We also added treatment related adverse effects to the secondary outcomes to enrich the results

  7. We added description in the Data synthesis section 'SDchange were unavailable in the original report, we imputed standard deviations for changes from baseline with the following technique: SDchange = (SDbaseline2 + SDfinal2 ‐ 2*Corr*SDbaseline*SDfinal)0.5. Default value (0.8) imputed for the correlation value' to provide more detailed methodology.

  8. We added the following to the Sensitivity analysis section: 'when we came across studies where the standard deviation of changes from baseline was missing, we imputed the missing standard deviation using an imputed value, Corr, for the correlation coefficient. Besides the default value (0.8), we used different hypothesized values of Corr based on reasoned argument to determine whether the overall result of the analysis was robust to the use of imputed correlation coefficients', to provide more detailed methodology.

  9. We did not perform funnel plots because there were no more than three trials in each analysis.

  10. Since all the included studies had high risk of bias, we did not perform sensitivity analysis. It was only possible to perform subgroup analysis according to the types of surgery and interventions because of the sparse data in other groups.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Adult; Humans;

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Flow diagram of study selection process.
Figuras y tablas -
Figure 1

Flow diagram of study selection process.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Forest plot of comparison: 1 All‐cause mortality, outcome: 1.1 All‐cause mortality.
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Figure 4

Forest plot of comparison: 1 All‐cause mortality, outcome: 1.1 All‐cause mortality.

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Forest plot of comparison: 1 ACEIs or ARBs versus placebo, outcome: 1.2 ST‐elevation or new Q wave in ECG test.
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Figure 5

Forest plot of comparison: 1 ACEIs or ARBs versus placebo, outcome: 1.2 ST‐elevation or new Q wave in ECG test.

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Forest plot of comparison: 1 ACEIs or ARBs versus placebo, outcome: 1.3 Cardiac index.
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Figure 6

Forest plot of comparison: 1 ACEIs or ARBs versus placebo, outcome: 1.3 Cardiac index.

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Forest plot of comparison: 1 ACEIs or ARBs versus placebo, outcome: 1.4 Rate of perioperative cerebrovascular complications.
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Figure 7

Forest plot of comparison: 1 ACEIs or ARBs versus placebo, outcome: 1.4 Rate of perioperative cerebrovascular complications.

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Forest plot of comparison: 1 ACEIs or ARBs versus placebo, outcome: 1.5 Length of hospital stay.
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Figure 8

Forest plot of comparison: 1 ACEIs or ARBs versus placebo, outcome: 1.5 Length of hospital stay.

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Comparison 1 ACEIs or ARBs versus placebo, Outcome 1 All cause mortality.
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Analysis 1.1

Comparison 1 ACEIs or ARBs versus placebo, Outcome 1 All cause mortality.

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Comparison 1 ACEIs or ARBs versus placebo, Outcome 2 ST‐elevation or new Q wave in ECG test.
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Analysis 1.2

Comparison 1 ACEIs or ARBs versus placebo, Outcome 2 ST‐elevation or new Q wave in ECG test.

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Comparison 1 ACEIs or ARBs versus placebo, Outcome 3 Cardiac index.
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Analysis 1.3

Comparison 1 ACEIs or ARBs versus placebo, Outcome 3 Cardiac index.

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Comparison 1 ACEIs or ARBs versus placebo, Outcome 4 Rate of perioperative cerebrovascular complications.
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Analysis 1.4

Comparison 1 ACEIs or ARBs versus placebo, Outcome 4 Rate of perioperative cerebrovascular complications.

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Comparison 1 ACEIs or ARBs versus placebo, Outcome 5 Length of hospital stay.
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Analysis 1.5

Comparison 1 ACEIs or ARBs versus placebo, Outcome 5 Length of hospital stay.

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Summary of findings for the main comparison. ACEIs or ARBs compared to placebo for preventing surgery‐related mortality and morbidity in adults

ACEIs or ARBs compared to placebo for preventing surgery‐related mortality and morbidity in adults

Patient or population: Patients undergoing any type of surgery under general anaesthesia receiving ACEIs or ARBs perioperatively
Settings: All settings
Intervention: ACEIs or ARBs
Comparison: Placebo

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Placebo

ACEIs or ARBs

All‐cause mortality

Study population

RR 1.61
(0.44 to 5.85)

419
(3 studies)

⊕⊝⊝⊝
very low1

All the included trials were at high risk of bias.

Total sample size is lower than the calculated.

Duration of follow‐up: until discharge from hospital

16 per 1000

25 per 1000
(7 to 90)

Moderate

7 per 1000

11 per 1000
(3 to 41)

Risk of acute myocardial ischaemia

Study population

RR 0.55
(0.14 to 2.26)

345
(2 studies)

⊕⊝⊝⊝
very low1

All the included trials were at high risk of bias.

Total sample size is lower than the calculated.

Duration of follow‐up: until discharge from hospital

30 per 1000

16 per 1000
(4 to 67)

Moderate

56 per 1000

31 per 1000
(8 to 127)

Congestive heart failure

The mean cardiac index in the intervention groups was
0.6 higher
(0.7 to 0.5 higher)

‐

34
(2 studies)

⊕⊝⊝⊝
very low1

All the included trials were at high risk of bias.

Total population size is less than 400.

Duration of follow‐up: not specified

Hypotension

‐

RR 1.95 (0.86 to 4.41)

298 (1 study)

⊕⊝⊝⊝
very low1

All the included trials were at high risk of bias.

Total population size is less than 400.

Duration of follow‐up: not specified

Rate of perioperative cerebrovascular complications

Study population

RR 0.48
(0.18 to 1.28)

459
(3 studies)

⊕⊝⊝⊝
very low1

All the included trials were at high risk of bias.

Duration of follow‐up: until discharge from hospital (Billings 2012; Pretorius 2012); 90 days after surgery (Flesch 2009)

50 per 1000

24 per 1000
(9 to 65)

Moderate

71 per 1000

34 per 1000
(13 to 92)

Length of hospital stay

The mean length of hospital stay in the intervention groups was
0.54 lower
(0.93 lower to 0.16 lower)

‐

372
(2 studies)

⊕⊝⊝⊝
very low1

All the included trials were at high risk of bias.

Total population size is less than 400.

Duration of follow‐up: until discharge from hospital

Treatment related adverse events

‐

‐

‐

385 (2 studies)

⊕⊝⊝⊝
very low1

All the included trials were at high risk of bias.

Total population size is less than 400.

Authors did not provided detailed information on adverse events, which made the synthesis of the results less clinically relevant.

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
ACEIs: angiotensin‐converting enzyme inhibitors; ARBs: angiotensin II type 1 receptor blockers; CI: confidence interval; ECG: electrocardiograph; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Downgraded by three levels due to very serious study limitations (all the trials included were at high risk of bias) and serious imprecision (total population size is less than 400).

Figuras y tablas -
Summary of findings for the main comparison. ACEIs or ARBs compared to placebo for preventing surgery‐related mortality and morbidity in adults
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Table 1. Rate of hypotension

Outcome or subgroup

Studies

Participants

Statistical method

Effect estimate

Rate of hypotension

1

298

Risk Ratio (M‐H, Fixed, 95% CI)

1.95 [0.86, 4.41]

Risk ratio < 1 favours angiotensin‐converting enzyme inhibitors and angiotensin II type 1 receptor blockers group. Risk ratio > 1 favours control group.

Figuras y tablas -
Table 1. Rate of hypotension
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Table 2. Glomerular filtration rate

Outcome or subgroup

Studies

Participants

Statistical method

Effect estimate

Glomerular filtration rate

1

16

Mean Difference (IV, Random, 95% CI)

‐1.40 [‐10.30, 7.50]

IV ‐ inverse variance

IV: intravenous
Figuras y tablas -
Table 2. Glomerular filtration rate
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Comparison 1. ACEIs or ARBs versus placebo

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 All cause mortality Show forest plot

3

419

Risk Ratio (M‐H, Fixed, 95% CI)

1.61 [0.44, 5.85]

2 ST‐elevation or new Q wave in ECG test Show forest plot

2

345

Risk Ratio (M‐H, Fixed, 95% CI)

0.55 [0.14, 2.26]

3 Cardiac index Show forest plot

2

34

Mean Difference (IV, Random, 95% CI)

‐0.60 [‐0.70, ‐0.50]

4 Rate of perioperative cerebrovascular complications Show forest plot

3

459

Risk Ratio (M‐H, Fixed, 95% CI)

0.48 [0.18, 1.28]

5 Length of hospital stay Show forest plot

2

372

Mean Difference (IV, Fixed, 95% CI)

‐0.54 [‐0.93, ‐0.16]
Figuras y tablas -
Comparison 1. ACEIs or ARBs versus placebo
Ir a la tabla de la revisión