Cardiovascular Risk Not Key in Presurgical Med Management

TOPLINE:

The STOP-or-NOT study of patients undergoing major noncardiac surgery found no difference in the postoperative risk for death or major complications in those who continued or discontinued treatment with renin-angiotensin system inhibitors (RASi) prior to the procedure. A new post hoc analysis of the randomized controlled trial found stratification of preoperative cardiovascular risk does not affect patient outcomes for the strategy, either.

METHODOLOGY:

• Researchers conducted a post hoc analysis of the multicenter STOP-or-NOT randomized clinical trial, which included patients at 40 hospitals in France between January 2018 and April 2023, with a 28-day postoperative follow-up.
• Participants included 2222 patients (median age, 68 years, 35% women) who had been treated with RASi agents for at least 3 months before undergoing major noncardiac surgery.
• Patients were randomly assigned to either continue taking their RASi until the day of surgery or discontinue the medication 48 hours before the procedure.
• Primary outcome measures were a composite of all-cause mortality and major postoperative complications. Secondary outcomes included major cardiovascular events and acute kidney injury.
• The researchers used the Revised Cardiac Risk Index (RCRI), the American University of Beirut-HAS2 Cardiovascular Risk Index, and systolic blood pressure prior to randomization to assess cardiovascular risk.

TAKEAWAY:

• Using the RCRI, 592 patients were categorized as low risk, 1095 as intermediate-low risk, 418 as intermediate-high risk, and 117 as high risk.
• The American University of Beirut-HAS2 score categorized 1049 patients as low risk, 727 as intermediate-low risk, 333 as intermediate-high risk, and 113 as high risk.
• While the risk for postoperative complications and major cardiovascular events varied with a person’s score on the RCRI, continuing or discontinuing RASi was not associated with an increased risk for surgical complications.

IN PRACTICE:

“This study found that preoperative cardiovascular risk did not affect patient outcomes with respect to the strategy of continuing vs discontinuing RASi before major noncardiac surgery, suggesting that the decision to continue or discontinue RASi should not be influenced by a patient’s preoperative cardiovascular risk assessment,” the researchers wrote.

SOURCE:

The study was led by Matthieu Legrand, MD, PhD, of the Department of Anesthesia and Perioperative Care at the University of California, San Francisco. It was published online on June 25 in JAMA Cardiology.

LIMITATIONS:

The researchers acknowledged several limitations of the research, including how the sample size may have limited the ability to detect complications with small effects in subpopulations. The absence of systematic postoperative troponin measurements also reduced sensitivity in detecting myocardial injury.

DISCLOSURES:

Several of the authors disclosed receiving grants from the National Institutes of Health, the Department of Defense, Edwards Lifesciences, Nordic Pharma, and others.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.