Key result
Effective preoperative RAAS inhibition is linked to less postoperative myocardial injury independent of holding strategy.
Why the study?
Hypertension therapy in older adults is often suboptimal, partly due to inadequate RAAS suppression, and it was hypothesized that distinct endotypes of preoperative RAAS activation associate with myocardial injury.
Are distinct endotypes of RAAS activation before noncardiac surgery associated with increased risk of myocardial injury in older adults?
RCT
Double-blind
Randomized to continue or stop RAAS inhibitors
Yes
Are distinct endotypes of RAAS activation before noncardiac surgery associated with increased risk of myocardial injury in older adults?
Effective preoperative RAAS inhibition is associated with a lower risk of myocardial injury after noncardiac surgery, independent of whether RAAS inhibitors are stopped or continued preoperatively.
Ensuring effective preoperative RAAS inhibition may lower myocardial injury risk after noncardiac surgery; extends evidence beyond continuation decisions.
BACKGROUND: Hypertension therapy in older adults is often suboptimal, in part because of inadequate suppression of the renin-angiotensin-aldosterone system (RAAS). We hypothesised that distinct endotypes of RAAS activation before noncardiac surgery are associated with increased risk of myocardial injury. METHODS: This was a prespecified exploratory analysis of a multicentre randomised controlled trial (ISRCTN17251494) which randomised patients ≥60 yr old undergoing elective noncardiac surgery to either continue or stop RAAS inhibitors (determined by pharmacokinetic profiles). Unsupervised hierarchical cluster analysis identified distinct groups of patients with similar RAAS activation from samples obtained before induction of anaesthesia, quantified by enzyme-linked immunoassays for plasma renin, aldosterone, angiotensin-converting enzyme 2, and dipeptidyl peptidase-3. The primary outcome, masked to investigators and participants, was myocardial injury (plasma high-sensitivity troponin-T). RESULTS: ), compared with clusters 1 and 3 which had higher rates of myocardial injury. CONCLUSIONS: This mechanistic exploratory analysis suggests that effective preoperative RAAS inhibition is associated with lower risk of myocardial injury after noncardiac surgery, independent of stopping or continuing RAAS inhibitors before surgery. CLINICAL TRIAL REGISTRATION: ISRCTN17251494.
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Arroyo et al. (2024) conducted an RCT in Elective noncardiac surgery. Continue RAAS inhibitors vs. Stop RAAS inhibitors was evaluated on Myocardial injury (plasma high-sensitivity troponin-T). Effective preoperative RAAS inhibition is associated with a lower risk of myocardial injury after noncardiac surgery, independent of stopping or continuing RAAS inhibitors before surgery.
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