Preoperative angiotensin-converting enzyme inhibitors protect myocardium from ischemia during coronary artery bypass graft surgery.
OBJECTIVE
Coronary artery bypass graft surgery may result in perioperative myocardial injury during cardioplegic arrest. Angiotensin-converting enzyme (ACE) inhibitors protect the myocardium from ischemia in several clinical conditions, but no previous study has attempted to evaluate the impact of preoperative ACE inhibitor therapy on myocardial protection in patients undergoing coronary artery bypass graft surgery.


METHODS
A propensity score-based analysis of 481 patients undergoing isolated on-pump coronary artery bypass graft surgery was carried out, among which 245 patients received preoperative ACE inhibitors and 236 patients did not. Perioperative myocardial injury was assessed by ischemia marker cardiac troponin I (cTnI).


RESULTS
Preoperative cTnI concentration was similar for patients receiving ACE inhibitors and those who did not [0.1 ng/ml (0.06-0.19) versus 0.1 ng/ml (0.06-0.19); P = 0.3]. Postoperative cTnI peak concentration was lower in patients receiving preoperative ACE inhibitors [1.6 ng/ml (1.05-3.4) versus 2.4 ng/ml (1.13-6.10); P = 0.0006]. After adjusting for propensity score and covariates, preoperative ACE inhibitors were found to decrease postoperative cTnI peak concentration (beta = -0.12; P = 0.004). Other independent predictors of postoperative cTnI peak concentration were female gender, emergency surgery, number of distal anastomoses and aortic cross clamp time. Overall, operative mortality rate was 16/481 (3.3%). Patients receiving preoperative ACE inhibitors had a lower rate of postoperative myocardial infarction (2.0 versus 4.2%; P = 0.25) and low cardiac output syndrome (3.6 versus 6.3%; P = 0.24).


CONCLUSIONS
ACE inhibitors prior to surgery confer added myocardial protection during surgical revascularization. Prospective, randomized clinical trials will be necessary to better define the role of ACE inhibitors in improving outcomes when they are prescribed prior to coronary artery bypass graft surgery.
Cardiac Surgery Department, II School of Medicine, University of Rome La Sapienza, Policlinico S. Andrea, Rome, Italy. u2benedetto@libero.it
Umberto
U
Benedetto
Giovanni
G
Melina
Fabio
F
Capuano
Cosimo
C
Comito
Roberto
R
Bianchini
Caterina
C
Simon
Simone
S
Refice
Emiliano
E
Angeloni
Riccardo
R
Sinatra
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage*; D015415:Biomarkers / Q000097:blood; D001026:Coronary Artery Bypass / Q000009:adverse effects* / Q000401:mortality; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000209:etiology / Q000401:mortality / Q000473:pathology / Q000517:prevention & control*; D009206:Myocardium / Q000378:metabolism / Q000473:pathology*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D019210:Troponin I / Q000097:blood
D000806:Angiotensin-Converting Enzyme Inhibitors; D015415:Biomarkers; D019210:Troponin I