title: Angiotensin Receptor Blockade Improves Cardiac Surgical Outcomes in Patients With Metabolic Syndrome.
abstract: BACKGROUND
  Perioperative use of angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEis) in patients undergoing cardiac operations remains controversial. The current practice of discontinuing renin-angiotensin-system inhibitors preoperatively may negate their beneficial effects in vulnerable populations, including patients with metabolic syndrome, who exhibit elevated renin-angiotensin system activity. We hypothesized that preoperative ARB use is associated with reduced incidence of postoperative complications, compared with ACEi or no drug, in patients with metabolic syndrome undergoing coronary artery bypass grafting.
  
  
  METHODS
  We used propensity matching to derive a cohort of 1,351 patients from 2,998 who underwent coronary artery bypass grafting based on preoperative use of ARBs, ACEis, or no renin-angiotensin-system inhibitors. Our primary end point was a composite of adverse events occurring within 30 days after the operation: new-onset atrial fibrillation/flutter, arrhythmia requiring cardioversion, perioperative myocardial infarction, acute renal failure, need for dialysis, cerebrovascular accidents, acute respiratory failure, or perioperative death.
  
  
  RESULTS
  At least one adverse event occurred in 524 (38.8%) of matched cohort patients (1,184 [39.6% of all patients]). Adjusting for European System for Cardiac Operative Risk Evaluation and metabolic syndrome in the matched cohort, preoperative use of ARBs was associated with a lower incidence of adverse events in patients with metabolic syndrome compared with preoperative use of no renin-angiotensin-system inhibitors (odds ratio, 0.43; 95% confidence interval, 0.19 to 0.99) or ACEis (odds ratio, 0.38; 95% confidence interval, 0.16 to 0.88).
  
  
  CONCLUSIONS
  Preoperative use of ARBs, but not ACEis, confers a benefit within 30 days after cardiac operations in patients with metabolic syndrome, suggesting potential efficacy differences of these drug classes in reducing cardiovascular morbidity and death in ambulatory vs surgical patients.
authors.affiliation: Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North California. Electronic address: michael.manning@dm.duke.edu.
authors.forename: Michael W
authors.initials: MW
authors.lastname: Manning
authors.affiliation: Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North California.
authors.forename: Mary
authors.initials: M
authors.lastname: Cooter
authors.affiliation: Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North California.
authors.forename: Joseph
authors.initials: J
authors.lastname: Mathew
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, North California; Duke Clinical Research Institute, Duke University Medical Center, Durham, North California.
authors.forename: John
authors.initials: J
authors.lastname: Alexander
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, North California; Duke Clinical Research Institute, Duke University Medical Center, Durham, North California.
authors.forename: Eric
authors.initials: E
authors.lastname: Peterson
authors.affiliation: Department of Cardiovascular Sciences, East Carolina Heart Institute, East Carolina University, Greenville, North California.
authors.forename: T Bruce
authors.initials: TB
authors.lastname: Ferguson
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, North California; Duke Clinical Research Institute, Duke University Medical Center, Durham, North California.
authors.forename: Renato
authors.initials: R
authors.lastname: Lopes
authors.affiliation: Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North California; Duke Clinical Research Institute, Duke University Medical Center, Durham, North California.
authors.forename: Mihai
authors.initials: M
authors.lastname: Podgoreanu
mesh_terms: D000368:Aged; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000150:complications / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D024821:Metabolic Syndrome / Q000150:complications* / Q000188:drug therapy; D016017:Odds Ratio; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D011446:Prospective Studies; D018570:Risk Assessment; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors