title: Thirty-day mortality risk associated with the postoperative nonresumption of angiotensin-converting enzyme inhibitors: a retrospective study of the Veterans Affairs Healthcare System.
abstract: BACKGROUND
  Angiotensin-converting enzyme inhibitors (ACE-Is) are a widely used class of cardiovascular medication. However, limited data exist on the risks of postoperative nonresumption of an ACE-I.
  
  
  OBJECTIVE
  To evaluate the factors and 30-day mortality risks associated with the postoperative nonresumption of an ACE-I.
  
  
  METHODS
  A retrospective cohort study.
  
  
  METHODS
  Veterans Affairs (VA) Healthcare System.
  
  
  METHODS
  A total of 294,505 admissions in 240,978 patients with multiple preoperative prescription refills (>3) for an ACE-I who underwent inpatient surgery from calendar years 1999 to 2012.
  
  
  METHODS
  None.
  
  
  METHODS
  We classified surgical admissions based upon the timing of postoperative resumption of an ACE-I prescription from the day of surgery through postoperative days 0 to 14 and 15 to 30, and collected 30-day mortality data. We evaluated the relationship between 30-day mortality and the nonresumption of an ACE-I from postoperative day 0 to 14 using proportional hazard regression models, adjusting for patient- and hospital-level risk factors. Sensitivity analyses were conducted using more homogeneous subpopulations and propensity score models.
  
  
  RESULTS
  Twenty-five percent of our cohort did not resume an ACE-I during the 14 days following surgery. Nonresumption of an ACE-I within postoperative day 0 to 14 was independently associated with increased 30-day mortality (hazard ratio: 3.44; 95% confidence interval: 3.30-3.60; P < 0.001) compared to the restart group. Sensitivity analyses maintained this relationship.
  
  
  CONCLUSIONS
  Nonresumption of an ACE-I is common after major inpatient surgery in the large VA Health Care System. Restarting of an ACE-I within postoperative day 0 to 14 is, however, associated with decreased 30-day mortality. Careful attention to the issue of timely reinstitution of chronic medications such as an ACE-I is indicated.
authors.affiliation: Anesthesia Service, Veterans Affairs Palo Alto Health Care System, Palo Alto and Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, California.
authors.forename: Seshadri C
authors.initials: SC
authors.lastname: Mudumbai
authors.forename: Steven
authors.initials: S
authors.lastname: Takemoto
authors.forename: Brian A
authors.initials: BA
authors.lastname: Cason
authors.forename: Selwyn
authors.initials: S
authors.lastname: Au
authors.forename: Anjali
authors.initials: A
authors.lastname: Upadhyay
authors.forename: Arthur W
authors.initials: AW
authors.lastname: Wallace
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000188:drug therapy; D003920:Diabetes Mellitus / Q000188:drug therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000188:drug therapy / Q000401:mortality*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D012495:San Francisco; D013997:Time Factors; D014481:United States; D014728:Veterans / Q000706:statistics & numerical data*
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors