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OBJECTIVES: Many patients undergoing abdominal aortic aneurysm repair (AAA), either open or endovascular (EVAR) are on preoperative angiotensin converting enzyme inhibitors (ACEIs). Despite their prevalence, the impact of these medications on the outcomes of AAA on a population level remains unknown. The objective of this study was to evaluate preoperative administration of ACEIs and evaluate their impact on perioperative and longitudinal outcomes.
METHODS: Patients at age 50 years old and above were selected from the Medicare MedPAR and Part D files (2007-2008) using ICD-9-CM diagnosis code for non-ruptured AAA and procedure codes for OPEN and EVAR. Preoperative ACEI use was identified by querying the National Drug Code Directory and Part D files. Chi-square test, multivariable logistic regression, Kaplan-Meier and Cox regression methods were utilized.
RESULTS: 19,323 patients were identified; 14,602 (75.6%) underwent EVAR while 4,721 (24.4%) patients underwent OPEN AAA repair. A total of 5,366 (27.8%) patients were prescribed an ACEI prior to their surgery. Overall hospital mortality in patients on ACEI prior to their operation was not statistically different (2.27% vs. 2.19%) nor were 30-day (2.89% vs. 2.83%), 90-day (4.81% vs. 5.01%) and 365-day (10.19% vs. 10.68%) mortalities, respectively. Overall differences in complications rates were not statistically significant (13.18% vs. 12.26%). No significant differences were noted for cardiac complications including MI. However, postoperative renal complications were greater in the group on ACEI after both EVAR (6.18% vs. 4.98%, P = 0.004) and open AAA repair (17.29% vs. 14.98%, P=0.04). After adjusting for age, gender, race, co-morbidities and type of procedure in multivariable logistic regression model, hospital mortality (OR=1.33; 95%CI 1.07-1.66, P=0.01), 30-day mortality (OR=1.26; 95%CI 1.03-1.53, P=0.02) and 90-day mortality (OR=1.16; 95%CI 1.001-1.36, P=0.048) were increased with ACEI.
CONCLUSIONS: Use of ACEI before open AAA and EVAR was not associated with cardiac or survival benefits. After adjusting for age, gender, race, procedure, and comorbidities the use of ACEI preoperatively was associated with an increased mortality, although this may be secondary to the patient population taking ACEIs or other unmeasured confounders. Further focused prospective evaluation of preoperative ACEI is warranted to assess ACEIs and their associated outcomes in aortic surgery.