Cardiovascular responses to anesthetic induction in patients chronically treated with angiotensin-converting enzyme inhibitors

Abstract

Purpose: To investigate the effects of chronic ACE inhibition on cardiac neural function following induction of general anesthesia in patients with underlying coronary artery disease. Method:In a prospective case-control study, heart rate variability (HRV) and baroreflex control were compared preoperatively and 30 min after anesthesia induction in patients receiving, or not, ACEI (n=16, control group and n=16, ACEI group). All patients had normal cardiac function and anesthesia consisted of a fixed dose regimen of fentanyl and midazolam. Anesthesia-related hypotension was defined by systolic blood pressure < 90 mmHg. Spectral density of HRV was calculated for low frequency and high frequency bands (LF, from 0.05 to 0.15 Hz and HF, from > 0.15 to 0.6 Hz). Baroreflex sensitivity was estimated after blood pressure changes induced by injections of phenylephrine (PHE) and nitroglycerin (NTG). Results:The HRV parameters and baroreflex sensitivity were not different between groups, during the awake and anesthesia periods. Anesthesia produced similar reduction in total HRV in the Control and ACEI groups (-93 ± 28% vs -89 ± 32%,) and in baroreflex sensitivity during NTG (-64 ± 21% vs -54 ± 17%) or PHE tests (-74 ± 25% vs -72 ± 22%). Anesthesia-related hypotension occurred in nine patients in the ACEI group (vs two controls). Although the hypertensive response to phenylephrine was greater after anesthesia in both groups, the sensitivity to phenylephrine was attenuated in those patients experiencing hypotension in the ACEI group. Conclusions: Chronic preoperative treatment with ACEIs does not influence cardiac autonomic regulation and anesthetic-induced hypotensive episodes are mainly attributed to decreased -adrenergic vasoconstrictive response.Objectif : Rechercher les effets d'une inhibition chronique de l'ECA sur la fonction neurale cardiaque à la suite de l'induction d'une anesthésie générale chez des patients qui présentent une cardiopathie ischémique sous-jacente.Méthode : Lors d'une étude prospective cas-témoins, la variabilité de la fréquence cardiaque (VFC) et le contrôle baroréflexe ont été comparés avant l'opération et 30 min après l'induction de l'anesthésie chez des patients qui reçoivent, ou non, un IECA (groupe témoin : n = 16, groupe IECA : n = 16). Tous les patients présentaient une fonction cardiaque normale et l'anesthésie comprenait un schéma posologique fixe de fentanyl et de midazolam. On a défini l'hypotension reliée à l'anesthésie comme la tension artérielle systolique < 90 mmHg. La densité spectrale de la VFC a été calculée pour des bandes de basses et de hautes fréquences (BF, de 0,05 à 0,15 Hz et HF, de > 0,15 à 0,6 Hz). La sensibilité baroréflexe a été évaluée après les changements de pression sanguine induits par les injections de phényléphrine (PHE) et de nitroglycérine (NTG).Résultats : Les paramètres de la VFC et la sensibilité baroréflexe n'ont pas présenté de différence intergroupe pendant les périodes d'éveil et d'anesthésie. L'anesthésie a produit une réduction similaire de la VFC total...

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

“…In 1 report, intraoperative hypotension was associated with a greater incidence of perioperative cardiac and renal complications than intraoperative hypertension, although other studies have not shown this. 78,[91][92][93][94][95][96] Several authors have suggested withholding ACE inhibitors and angiotensin receptor antagonists the morning of surgery. [97][98][99] Consideration should be given to restarting ACE inhibitors in the postoperative period only after the patient is euvolemic, to decrease the risk of perioperative renal dysfunction.…”

Management of comorbidities in ambulatory anesthesia: a review

“…32 Studies have shown that patients who are on long-term treatment, with ACE inhibitors and angiotensin receptor blockers, experience hypotension that requires vasopressor treatment more often after induction of anesthesia, than those in whom such medications have been withheld on the day of surgery. [33][34][35] Withdrawal of hypertensive medications during the preoperative period may result in rebound HTN that may require immediate treatment. Although the presence of labile BP during the perioperative period has been shown to increase the risk of stroke, acute kidney injury (AKI), and 30-day mortality in patients undergoing cardiac surgery, 36 evidence is limited in the ambulatory patient population.…”

Herzklappenerkrankungen

“…Die Fortführung einer präoperativ bestehenden antihypertensiven Therapie zur Nachlastsenkung wird empfohlen, ist aber nicht durch große randomisierte Studien belegt. Bei perioperativer Einnahme von Angiotensinkonversionsenzym(ACE)-Hemmern und Angiotensin(AT)II-Rezeptor-Antagonisten sind perioperative Hypotonien und vasoplegische Syndrome beschrieben; der perioperative Umgang mit diesen Substanzklassen wird derzeit kontrovers diskutiert [28,29,30]. Liegt eine schwere AI mit progredienter linksventrikulärer Dysfunktion vor, wird ein Aortenklappenersatz vor elektiven nichtkardiochirurgischen Eingriffen empfohlen [10,31].…”