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Penggunaan ubat anti hipertensi ACE I atau ARB untuk mengurangkan risiko kematian dan morbiditi di kalangan orang dewasa sebelum pembedahan

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Referencias

Billings 2012 {published data only}

Billings FT, Balaguer JM, C‐Y, Wright P, Petracek MR, Byrne JG, et al. Comparative effects of angiotensin receptor blockade and ACE inhibition on the fibrinolytic and inflammatory responses to cardiopulmonary bypass. Clinical Pharmacology and Therapeutics 2012;91(6):1065‐73. [PUBMED: 22549281]CENTRAL

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Colson P, Ribstein J, Seguin JR, Marty‐Ane C, Roquefeuil B. Mechanisms of renal hemodynamic impairment during infrarenal aortic cross‐clamping. Anesthesia and Analgesia 1992;75(1):18‐23. [PUBMED: 1616156]CENTRAL

Flesch 2009 {published data only}

Flesch M, Knipp S, Kessler G, Geissler HJ, Massoudy P, Wilhelm H, et al. ARTA: AT1‐receptor blocker therapy in patients undergoing coronary artery bypass grafting. Clinical Research in Cardiology: Official Journal of the German Cardiac Society 2009;98(1):33‐43. [PUBMED: 18853093]CENTRAL

Licker 1996 {published data only}

Licker M, Bednarkiewicz M, Neidhart P, Pretre R, Montessuit M, Favre H, et al. Preoperative inhibition of angiotensin‐converting enzyme improves systemic and renal haemodynamic changes during aortic abdominal surgery. British Journal of Anaesthesia 1996;76(5):632‐9. [PUBMED: 8688261]CENTRAL

Pretorius 2012 {published data only}

Pretorius M, Murray KT, Yu C, Byrne JG, Billings FT, Petracek MR, et al. Angiotensin‐converting enzyme inhibition or mineralocorticoid receptor blockade do not affect prevalence of atrial fibrillation in patients undergoing cardiac surgery. Critical Care Medicine 2012;40(10):2805‐12. [PUBMED: 22824930]CENTRAL

Ryckwaert 2001 {published data only}

Ryckwaert F, Colson P, Ribstein J, Boccara G, Guillon G. Haemodynamic and renal effects of intravenous enalaprilat during coronary artery bypass graft surgery in patients with ischaemic heart dysfunction. British Journal of Anaesthesia 2001;86(2):169‐75. [PUBMED: 11573655]CENTRAL

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Walter T, Helber U, Bail D, Heller W, Hoffmeister HM. Influence of ACE inhibition on myocardial damage, the Kallikrein‐Kinin system and hemostasis during cardiopulmonary bypass surgery. The Thoracic and Cardiovascular Surgeon 2002;50(3):150‐4. [PUBMED: 12077687]CENTRAL

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Benedetto U, Melina G, Capuano F, Comito C, Bianchini R, Simon C, et al. Preoperative angiotensin‐converting enzyme inhibitors protect myocardium from ischemia during coronary artery bypass graft surgery. Journal of Cardiovascular Medicine (Hagerstown, Md.) 2008;9(11):1098‐103. [PUBMED: 18852580]CENTRAL

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Boldt J, Schindler E, Harter K, Gorlach G, Hempelmann G. Influence of intravenous administration of angiotensin‐converting enzyme inhibitor enalaprilat on cardiovascular mediators in cardiac surgery patients. Anesthesia and Analgesia 1995;80(3):480‐5. [PUBMED: 7864411]CENTRAL

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Boldt J, Schindler E, Wollbruck M, Gorlach G, Hempelmann G. Cardiorespiratory response of intravenous angiotensin‐converting enzyme inhibitor enalaprilat in hypertensive cardiac surgery patients. Journal of Cardiothoracic and Vascular Anesthesia 1995;9(1):44‐9. [PUBMED: 7718754]CENTRAL

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Boldt J, Rothe G, Schindler E, Doll C, Gorlach G, Hempelmann G. Can clonidine, enoximone, and enalaprilat help to protect the myocardium against ischaemia in cardiac surgery?. Heart (British Cardiac Society) 1996;76(3):207‐13. [PUBMED: 8868976]CENTRAL

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Briot D, Schmitt JP, Coumaros G, Conraux C, Dupeyron JP. Captopril potentiation of the hypotension induced by halothane [Potentialisation par le captopril de l'hypotension induite par l'halothane]. Annales Francaises d'Anesthesie et de Reanimation 1988;7(1):22‐5. [PUBMED: 2831758]CENTRAL

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Cieciura T, Senatorski G, Rell K, Baczkowska T, Paczek L, Gradowska L, et al. Influence of angiotensin‐converting enzyme inhibitor treatment of the carotid artery intima‐media complex in renal allograft recipients. Transplantation Proceedings 2000;32(6):1335‐6. [PUBMED: 10995971]CENTRAL

Coca 2013 {published data only}

Coca SG, Garg AX, Swaminathan M, Garwood S, Hong K, Thiessen‐Philbrook H, et al. Preoperative angiotensin‐converting enzyme inhibitors and angiotensin receptor blocker use and acute kidney injury in patients undergoing cardiac surgery. Nephrology, Dialysis, Transplantation: Official Publication of the European Dialysis and Transplant Association ‐ European Renal Association 2013;28(11):2787‐99. [PUBMED: 24081864]CENTRAL

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Colson P, Ribstein J, Mimran A, Grolleau D, Chaptal PA, Roquefeuil B. Effect of angiotensin converting enzyme inhibition on blood pressure and renal function during open heart surgery. Anesthesiology 1990;72(1):23‐7. [PUBMED: 2404429]CENTRAL

Dag 2013 {published data only}

Dag O, Kaygin MA, Aydin A, Limandal HK, Arslan U, Kiymaz A, et al. Is administration of preoperative angiotensin‐converting enzyme inhibitors important for renal protection after cardiac surgery?. Renal Failure 2013;35(5):754‐60. [PUBMED: 23521631]CENTRAL

Dahl 2013 {published data only}

Dahl JS, Videbaek L, Poulsen MK, Pellikka PA, Veien K, Andersen LI, et al. Prevention of atrial fibrillation in patients with aortic valve stenosis with candesartan treatment after aortic valve replacement. International Journal of Cardiology 2013;165(2):242‐6. [PUBMED: 21907422]CENTRAL

Di Pasquale 1993 {published data only}

Di Pasquale P, Paterna S, Valenza M, Valdes L, Albano V, Trombino G, et al. Effects of captopril on myocardial protection during cardioplegia. International Journal of Cardiology 1993;42(3):225‐30. [PUBMED: 8138330]CENTRAL

Fontes 2012 {published data only}

Fontes ML, Varon J. Perioperative hypertensive crisis: newer concepts. International Anesthesiology Clinics 2012;50(2):40‐58. [PUBMED: 22481555]CENTRAL

Friedrich 2009 {published data only}

Friedrich A, Helmy T. Prevention of perioperative myocardial infarction. International Anesthesiology Clinics 2009;47(4):13‐36. [PUBMED: 19820476]CENTRAL

Heck 2012 {published data only}

Heck SL, Gulati G, Ree AH, Schulz‐Menger J, Gravdehaug B, Rosjo H, et al. Rationale and design of the prevention of cardiac dysfunction during an Adjuvant Breast Cancer Therapy (PRADA) Trial. Cardiology 2012;123(4):240‐7. [PUBMED: 23207160]CENTRAL

Heropoulos 1995 {published data only}

Heropoulos M, Schieren H, Seltzer JL, Bartkowski RR, Lessin J, Torjman M, et al. Intraoperative hemodynamic, renin, and catecholamine responses after prophylactic and intraoperative administration of intravenous enalaprilat. Anesthesia and Analgesia 1995;80(3):583‐90. [PUBMED: 7864430]CENTRAL

Ibrahim 2013 {published data only}

Ibrahim HN, Jackson S, Connaire J, Matas A, Ney A, Najafian B, et al. Angiotensin II blockade in kidney transplant recipients. Journal of the American Society of Nephrology 2013;24(2):320‐7. [PUBMED: 23308016]CENTRAL

Issa 2014 {published data only}

Issa N, Ortiz F, Reule SA, Kukla A, Kasiske BL, Mauer M, et al. The renin‐aldosterone axis in kidney transplant recipients and its association with allograft function and structure. Kidney International 2014;85(2):404‐15. [PUBMED: 23965522]CENTRAL

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Kerut EK, Geraci SA, Falterman C, Hunter D, Hanawalt C, Giles TD. Atherosclerotic renal artery stenosis and renovascular hypertension: clinical diagnosis and indications for revascularization. Journal of Clinical Hypertension (Greenwich, Conn.) 2006;8(7):502‐9. [PUBMED: 16849904]CENTRAL

Kortekaas 2014 {published data only}

Kortekaas KE, Meijer CA, Hinnen JW, Dalman RL, Xu B, Hamming JF, et al. ACE inhibitors potently reduce vascular inflammation, results of an open proof‐of‐concept study in the abdominal aortic aneurysm. PLoS One 2014;9(12):e111952. [PUBMED: 25474105]CENTRAL

Kottenberg‐Assenmacher 2008 {published data only}

Kottenberg‐Assenmacher E, Massoudy P, Jakob H, Philipp T, Peters J. Chronic AT1‐receptor blockade does not alter cerebral oxygen supply/demand ratio during cardiopulmonary bypass in hypertensive patients. Acta Anaesthesiologica Scandinavica 2008;52(1):73‐80. [PUBMED: 17976222]CENTRAL

Lazar 2008 {published data only}

Lazar HL. All coronary artery bypass graft surgery patients will benefit from angiotensin‐converting enzyme inhibitors. Circulation2008; Vol. 117, issue 1:6‐8. [PUBMED: 18172046]CENTRAL

Magnusson 1993 {published data only}

Magnusson L, Rebagliati M, Buchser E. Elevation of arterial pressure during surgery with a pneumatic tourniquet: an independent action of renin? [Elevation de la tension arterielle lors de chirurgie sous garrot pneumatique: un mecanisme independant de la renine?]. Canadian Journal of Anaesthesia/Journal canadien d'anesthesie 1993;40(7):596‐600. [PUBMED: 8403133]CENTRAL

Manche 1999 {published data only}

Manche A, Galea J, Busuttil W. Tolerance to ACE inhibitors after cardiac surgery. European Journal of Cardio‐Thoracic Surgery: Official Journal of the European Association for Cardio‐Thoracic Surgery 1999;15(1):55‐60. [PUBMED: 10077374]CENTRAL

McCarthy 1990 {published data only}

McCarthy GJ, Hainsworth M, Lindsay K, Wright JM, Brown TA. Pressor responses to tracheal intubation after sublingual captopril. A pilot study. Anaesthesia 1990;45(3):243‐5. [PUBMED: 2185673]CENTRAL

Muller 2000 {published data only}

Muller M, Schindler E, Kwapisz M, Klemm S, Akinturk H, Heidt M, et al. Effect of intraoperative angiotensin‐converting enzyme inhibition by quinaprilat on hypertension after coronary artery surgery. British Journal of Anaesthesia 2000;84(3):396‐8. [PUBMED: 10793603]CENTRAL

Pigott 1999 {published data only}

Pigott DW, Nagle C, Allman K, Westaby S, Evans RD. Effect of omitting regular ACE inhibitor medication before cardiac surgery on haemodynamic variables and vasoactive drug requirements. British Journal of Anaesthesia 1999;83(5):715‐20. [PUBMED: 10690132]CENTRAL

Poulsen 2014 {published data only}

Poulsen FR, Munthe S, Soe M, Halle B. Perindopril and residual chronic subdural hematoma volumes six weeks after burr hole surgery: a randomized trial. Clinical Neurology and Neurosurgery 2014;123:4‐8. [PUBMED: 25012003]CENTRAL

Proshchaev 2003 {published data only}

Proshchaev KI. Use of enalapril in the preparation of patients with arterial hypertension to the surgical procedures [Ispol'zovanie enalaprila glia podgotovki bol'nykh arterial'noi hypertension k khirurgicheskim vmeshatel'stvam]. Terapevticheskii arkhiv 2003;75(12):43‐7. [PUBMED: 14959469]CENTRAL

Schuetz 1998 {published data only}

Schuetz WH, Lindner KH, Georgieff M, Mueller S, Oertel F, Radermacher P, et al. The effect of i.v. enalaprilat in chronically treated hypertensive patients during cardiac surgery. Acta Anaesthesiologica Scandinavica 1998;42(8):929‐35. [PUBMED: 9773137]CENTRAL

Sharaf 2013 {published data only}

Sharaf A, Davoodi S, Karimi AA, Ahmadi H, Abbasi K, Fathollahi MS, et al. Impact of angiotensin‐converting enzyme inhibitors and angiotensin receptor blockers on mortality of coronary artery bypass grafting. Journal of Tehran University Heart Center 2013;8(4):177‐81. CENTRAL

Taniguchi 2008 {published data only}

Taniguchi FP. Renin inhibitors in cardiovascular surgery. Cardiovascular Drugs and Therapy/Sponsored by the International Society of Cardiovascular Pharmacotherapy2008; Vol. 22, issue 1:79‐80. [PUBMED: 17899347]CENTRAL

Tohmo 1993 {published data only}

Tohmo H, Karanko M, Scheinin M, Viinamaki O, Salonen M, Nieminen V. Enalapril premedication attenuates the blood pressure response to tracheal intubation and stabilizes postoperative blood pressure after controlled hypotension with sodium nitroprusside in neurovascular patients. Journal of Neurosurgical Anesthesiology 1993;5(1):13‐21. [PUBMED: 8431665]CENTRAL

Twersky 2014 {published data only}

Twersky RS, Goel V, Narayan P, Weedon J. The risk of hypertension after preoperative discontinuation of angiotensin‐converting enzyme inhibitors or angiotensin receptor antagonists in ambulatory and same‐day admission patients. Anesthesia and Analgesia 2014;118(5):938‐44. [PUBMED: 24681657]CENTRAL

Webb 1998 {published data only}

Webb CM, Underwood R, Anagnostopoulos C, Bennett JG, Pepper J, Lincoln C, et al. The effect of angiotensin converting enzyme inhibition on myocardial function and blood pressure after coronary artery bypass surgery‐‐a randomised study. European Journal of Cardio‐Thoracic Surgery: Official Journal of the European Association for Cardio‐Thoracic Surgery 1998;13(1):42‐8. [PUBMED: 9504729]CENTRAL

Zentner 2012 {published data only}

Zentner D, Pedagogos E, Yapanis A, Karapanagiotidis S, Kinghorn A, Alexiou A, et al. Can losartan and blood pressure control peri arteriovenous fistula creation ameliorate the early associated left ventricular hypertrophic response a randomised placebo controlled trial. BMC Research Notes 2012;5:260. [PUBMED: 22642740]CENTRAL

References to studies awaiting assessment

Fan 2016 {published data only}

Fan Y, Zhang D, Xiang D. Delayed protective effect of telmisartan on lung ischemia/reperfusion injury in valve replacement operations. Experimental and Therapeutic Medicine 2016;12(4):2577‐81. [PUBMED: 27698759 ]CENTRAL

Fuentes‐Reyes 2016 {published data only}

Fuentes‐Reyes RA, Pacheco‐Patiño MF, Ponce‐Escobedo AN, Muñoz‐Maldonado GE, Hernandez‐Guedea MA. [Impact of telmisartan on glomerular filtration in laparoscopic surgery. A double blinded randomised controlled study]. [Article in Spanish]. Cirugía y Cirujanos 2017;85(1):34‐40. [PUBMED: 27417705]CENTRAL

Tian 2015 {published data only}

Tian Y, Li H, Liu P, Xu JM, Irwin MG, Xia Z, et al. Captopril pretreatment produces an additive cardioprotection to isoflurane preconditioning in attenuating myocardial ischemia reperfusion injury in rabbits and in humans. Mediators of Inflammation 2015:819232. [PUBMED: 26273143 ]CENTRAL

Arora 2008

Arora P, Rajagopalam S, Ranjan R, Kolli H, Singh M, Venuto R, et al. Preoperative use of angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers is associated with increased risk for acute kidney injury after cardiovascular surgery. Clinical Journal of the American Society of Nephrology: CJASN 2008;3(5):1266‐73. [PUBMED: 18667735]

Blessberger 2014

Blessberger H, Kammler J, Domanovits H, Schlager O, Wildner B, Azar D, et al. Perioperative beta‐blockers for preventing surgery‐related mortality and morbidity. Cochrane Database of Systematic Reviews 2014, Issue 9. [DOI: 10.1002/14651858.CD004476.pub2; PUBMED: 25233038]

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References to other published versions of this review

Zou 2011

Zou Z, Yuan HB, Chen XY, Liu GJ, Shi XY. Perioperative angiotensin‐converting enzyme inhibitors or angiotensin II type 1 receptor blockers for preventing surgery‐related mortality and morbidity. Cochrane Database of Systematic Reviews 2011, Issue 7. [DOI: 10.1002/14651858.CD009210]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Billings 2012

Methods

Prospective randomized controlled trial

Participants

Adults scheduled for cardiac surgery involving cardiopulmonary bypass were eligible for the study

Mean age (years): 1. 66.1 ± 2.1; 2. 64.4 ± 2.1; 3. 67.0 ± 1.7

Sample size (male): 1. 28(9); 2. 24(12); 3. 22(10)

Interventions

1. placebo; 2. ramipril (2.5 mg on the first 3 days followed by 5 mg/day, with the dose reduced to 2.5 mg/day on the first postoperative day only); 3. candesartan (16 mg/day)

Outcomes

All‐cause mortality; rate of perioperative stroke; length of hospital stay

Notes

Intervention started 5 to 7 days before surgery

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Random allocation, but no details available

Allocation concealment (selection bias)

Unclear risk

No relevant description, and no further details available

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Double blind

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No relevant description

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Information on dropouts specified

Selective reporting (reporting bias)

Unclear risk

Protocol inaccessible

Other bias

Low risk

No other source of bias found

Colson 1992

Methods

Prospective randomized controlled trial

Participants

Scheduled for infrarenal aortic surgery because of aortic aneurysm (n = 8) or aorta occlusive disease (n = 16)

Mean age (years): 1. 63 ± 1; 2. 63 ± 3; 3. 58 ± 4

Sample size (male): 24(23)

Interventions

2 days before surgery, participants were allocated to 1 of 3 groups in randomized, double‐blind fashion: 1. control group; 2. nicardipine group; 3. enalapril group. The enalapril group received enalapril (10 mg twice daily), whereas the control and nicardipine groups received a placebo (1 tablet twice daily). The last dose of either enalapril or placebo was given at the time of preanaesthetic medication, approximately 2 h before surgery. Both treatments were well tolerated. At skin incision, nicardipine was administered to the nicardipine group (2 mg IV bolus injection, then 2 mg/h), and placebo (5% glucose solution) was infused in participants in the other groups

Outcomes

Glomerular filtration rate

Notes

Intervention started 2 days before surgery and continued until 2 h before surgery

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Random allocation, but no details available

Allocation concealment (selection bias)

Unclear risk

No relevant description, and no further details available

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Double blind, but no details available

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No relevant description

Incomplete outcome data (attrition bias)
All outcomes

High risk

No relevant description

Selective reporting (reporting bias)

Unclear risk

Protocol inaccessible

Other bias

Unclear risk

Funding source not reported

Flesch 2009

Methods

Prospective randomized controlled trial

Participants

Patients undergoing elective coronary artery bypass grafting

Mean age (years): 1. 71.0 ± 4.6; 2. 69.9 ± 4.6

Sample size (male): 1. 43(36); 2. 44(33)

Duration: 1. 84.1 ± 42.7 days; 2. 93.1 ± 41.5 days

Interventions

Eligible and consenting patients were enrolled 6 to 11 days before coronary artery bypass surgery. At this day, called visit 1. ACEIs or ARBs were to be discontinued if part of the previous medication. All other antihypertensive medications including long‐acting calcium channel blockers and beta blockers were allowed to be continued. Participants were randomized to receive either 8 mg of candesartan cilexetil or placebo. Treatment with the study drug was continued for 6 to 11 days until the day of operation. 1 day prior to CABG (visit 2) renal clearance was determined. 8 ± 3 days after CABG (visit 3) endpoint cognitive function tests were performed and renal clearance was determined again

Outcomes

Rate of perioperative stroke; incidence of treatment related adverse events

Notes

Drugs were given between 8 and 11 days prior to surgery

The 8th page of the study reported the results of adverse events.There were no significant differences in the number of patients with adverse events with candesartan and placebo. The majority of adverse events were non‐serious. And most adverse events were considered as unlikely or not related with the study medication. A possible causal relationship was indicated in two adverse events in 52 patients in the candesartan and three adverse events in 53 patients in the placebo group. The authors did not provide further information on adverse events including what the exact adverse events were. We have tried to contact the corresponding author via email but did not obtain any response.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Random allocation, but no details available

Allocation concealment (selection bias)

Unclear risk

No relevant description, and no further details available

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Double blind, but no details available

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No relevant description

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Information on dropouts specified

Selective reporting (reporting bias)

Unclear risk

Protocol inaccessible

Other bias

Unclear risk

Funding source not reported

Licker 1996

Methods

Prospective randomized controlled trial

Participants

Patients undergoing elective infrarenal aortic surgery because of aortic aneurysm or atherosclerotic occlusive disease

Mean age (years): 1. 68; 2. 69

Sample size (male): 1. 9 (7); 2. 11(10)

Interventions

1. enalapril 50 μg/kg diluted in 20 ml of normal saline and injected IV over 5 min. 2. same volume of saline solution

Outcomes

Cardiac index

Notes

The drugs were given 25 min before induction of anaesthesia

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Random allocation, but no details available

Allocation concealment (selection bias)

Unclear risk

No relevant description, and no further details available

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Double blind, but no details available

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No relevant description

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No dropouts

Selective reporting (reporting bias)

Unclear risk

Protocol inaccessible

Other bias

Unclear risk

Funding source not reported

Pretorius 2012

Methods

Prospective randomized controlled trial

Participants

Undergoing elective cardiac surgery including CABG or valvular surgery

Mean age (years): 1. 60.0 ± 12.0; 2. 58.7 ± 12.3; 3. 59.2 ± 12.3

Sample size (male): 1. 147(94); 2. 151(106); 3. 147(96)

Interventions

1 week to 4 days prior to surgery, participants were randomized to treatment with placebo, ramipril (2.5 mg the first 3 days followed by 5 mg/day, with the dose reduced to 2.5 mg/day on the first postoperative day only), or spironolactone (25 mg/day)

Outcomes

All‐cause mortality; ST segment change or new Q wave in ECG test; rate of perioperative stroke; length of hospital stay; hypotension; incidence of treatment related adverse events

Notes

Ramipril group: 2.5 mg the first 3 days followed by 5 mg/d, with the dose reduced to 2.5 mg/d on the first postoperative day only

The authors listed adverse events and serious adverse events in the table 3 but no further information in the main text. We have tried to contact the corresponding author via email but did not obtain any response.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Random allocation, but no details available

Allocation concealment (selection bias)

Unclear risk

No relevant description, and no further details available

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Double blind, but no details available

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

All electrocardiograms and rhythm strips were reviewed in a blinded fashion by a single cardiac electrophysiologist

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Information on dropouts specified

Selective reporting (reporting bias)

Unclear risk

Protocol inaccessible

Other bias

Low risk

No other source of bias found

Ryckwaert 2001

Methods

Prospective randomized controlled trial

Participants

Patients scheduled for elective CABG

Mean age (years): 1. 66.3 ± 4.2; 2. 60.1 ± 3.6

Sample size (male): 14(13)

Interventions

1. IV enalapril 1 mg at intervals of 6 h for 2 days, starting at the time of surgical incision 2. placebo

Outcomes

Cardiac index

Notes

Enalapril started at the time of surgical incision and lasted for 2 days

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Random allocation, but no details available

Allocation concealment (selection bias)

Unclear risk

No relevant description, and no further details available

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Double blind, but no details available

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No relevant description

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No dropouts

Selective reporting (reporting bias)

Unclear risk

Protocol inaccessible

Other bias

Unclear risk

Funding source not reported

Walter 2002

Methods

Prospective randomized controlled trial

Participants

Patients undergoing elective cardiopulmonary bypass surgery

Mean age (years): 1. 64.8 ± 1.7 2. 61.9 ± 2.0

Sample size (male): 1. 22(17); 2. 21(16)

Interventions

1. oral 7.5 mg enalapril on the first day and oral 20 mg/d enalapril on the following days

2. placebo

Outcomes

All‐cause mortality; concentration of creatine kinase, MB form
; ST segment change or new Q wave in ECG test; hypotension

Notes

Participants in enalapril group were given 7.5 mg on the first day

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Random allocation, but no details available

Allocation concealment (selection bias)

Unclear risk

No relevant description, and no further details available

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Double blind, but no details available

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No relevant description

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Information on dropouts specified

Selective reporting (reporting bias)

Unclear risk

Protocol inaccessible

Other bias

Low risk

No other source of bias found

ACEIs: angiotensin‐converting enzyme inhibitors
ARBs: angiotensin II type 1 receptor blockers
CABG: coronary artery bypass graft surgery
ECG: electrocardiograph
IV: intravenous
ST: the ST segment in electrocardiography

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Andres 2006

Drugs were not given perioperatively

Aronson 2011

Review

Arora 2012

Review

Bader 2012

Review

Benedetto 2008

Retrospective study

Boldt 1995a

The lead author has been accused of fraud, therefore the reliability of the results is questionable

Boldt 1995b

The lead author has been accused of fraud, therefore the reliability of the results is questionable

Boldt 1996

The lead author has been accused of fraud, therefore the reliability of the results is questionable. We tried to contact the other authors of the research Boldt 1996 but received no response. We have decided that it is not helpful to include primary studies in a review when the results of the studies are likely to be biased

Briot 1988

Did not measure our interested outcomes

Cieciura 2000

Not perioperative drug administration

Coca 2013

Not perioperative drug administration

Colson 1990

Did not measure our interested outcomes

Dag 2013

Retrospective study

Dahl 2013

Not perioperative drug administration

Di Pasquale 1993

Did not measure our interested outcomes

Fontes 2012

Review

Friedrich 2009

Review

Heck 2012

Participants receiving adjuvant breast cancer therapy

Heropoulos 1995

Did not measure our interested outcomes

Ibrahim 2013

Not perioperative drug administration

Issa 2014

Not perioperative drug administration

Kerut 2006

Review

Kortekaas 2014

The study design was not randomized. The data in the control group were retrieved from a biobank

Kottenberg‐Assenmacher 2008

Did not measure our interested outcomes

Lazar 2008

Review

Magnusson 1993

Increase of the arterial pressure during the application of a tourniquet

Manche 1999

Did not measure our interested outcomes

McCarthy 1990

Did not measure our interested outcomes

Muller 2000

Did not measure our interested outcomes

Pigott 1999

Participants were already on ACEI

Poulsen 2014

Participants in 1 group were already on ACEI 3 months prior to surgery

Proshchaev 2003

No relevant compression

Schuetz 1998

Did not measure our interested outcomes

Sharaf 2013

Retrospective study

Taniguchi 2008

Did not measure our interested outcomes

Tohmo 1993

Did not measure our interested outcomes

Twersky 2014

Not perioperative drug administration

Webb 1998

Did not measure our interested outcomes

Zentner 2012

Surgery under local anaesthesia only

ACEI: angiotensin‐converting enzyme inhibitor

Characteristics of studies awaiting assessment [ordered by study ID]

Fan 2016

Methods

Parallel randomized controlled trial

Participants

Patients diagnosed with rheumatic valve diseases undergoing heart valve replacement operations

Interventions

Telmisartan, captopril, and placebo

Outcomes

Pulmonary vascular resistance, A‐aDO2, pulmonary neutrophil count, SOD malondialdehyde, NO, angiotensin II; Complications and hospital time.

Notes

Fuentes‐Reyes 2016

Methods

Prospective, randomized, double‐blind study

Participants

Undergoing laparoscopic surgery

Interventions

Telmisartan and placebo

Outcomes

Plasma creatinine, creatinine clearance, etc.

Notes

Tian 2015

Methods

Randomized trial

Participants

Patients selected for heart valve replacement surgery

Interventions

Untreated control, captopril pretreatment, single dose captopril

Outcomes

ICU stay, hospital stay, death; Postischemic Myocardial Cellular Injury and Proinflammatory Cytokines.

Notes

Data and analyses

Open in table viewer
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]

Analysis 1.1

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

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

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]

Analysis 1.2

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

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

3 Cardiac index Show forest plot

2

34

Mean Difference (IV, Random, 95% CI)

‐0.60 [‐0.70, ‐0.50]

Analysis 1.3

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

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

4 Rate of perioperative cerebrovascular complications Show forest plot

3

459

Risk Ratio (M‐H, Fixed, 95% CI)

0.48 [0.18, 1.28]

Analysis 1.4

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

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

5 Length of hospital stay Show forest plot

2

372

Mean Difference (IV, Fixed, 95% CI)

‐0.54 [‐0.93, ‐0.16]

Analysis 1.5

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

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

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

Flow diagram of study selection process.

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.

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

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

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

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

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

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

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

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

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

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

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

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

Comparison 1 ACEIs or ARBs versus placebo, Outcome 1 All cause mortality.
Figuras y tablas -
Analysis 1.1

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

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

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

Comparison 1 ACEIs or ARBs versus placebo, Outcome 3 Cardiac index.
Figuras y tablas -
Analysis 1.3

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

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

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

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

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

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
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
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
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