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Ann Thorac Surg 1998;66:2163
© 1998 The Society of Thoracic Surgeons

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Correspondence

Angiotensin-converting enzyme inhibitors during acute revascularization

^a Department of Cardiothoracic Surgery, Boston University School of Medicine, Boston, MA 02118, USA

To the Editor

My coauthors and I greatly appreciated the invited commentary by Dr Sellke regarding our article "Beneficial Effects of Angiotensin-Converting Enzyme Inhibitors During Acute Revascularization" [1]. Doctor Sellke notes that some studies have shown an increased need for pressor agents to maintain blood pressure in patients undergoing heart operations who have been on long-term angiotensin-converting enzyme (ACE) inhibitor therapy. He postulates that because ACE inhibitors prevent the degradation of bradykinin, a potent vasodilator and mediator of vascular permeability, ACE inhibitors could significantly increase systemic inflammation and fluid requirements postoperatively and thus alter patient outcomes.

In our article, we noted that the antiischemic effects of ACE inhibitors in our study occurred in dosages that resulted in no significant alterations in systemic hemodynamics. This observation has been reported by other investigators, including Dr Sellke’s group [2]. In our clinical practice, although we have noted that some patients who have been treated preoperatively with long-term ACE inhibitors have required short periods of pressor support with neosynephrine, there have been no adverse outcomes. In fact, we noted substantial improvement in the ejection fraction of many of these patients, which made them better surgical candidates.

We anticipate that further refinements in ACE inhibitor therapy will produce drugs that will have maximal antiischemic effects with minimal vasodilation. Because of the outstanding results of ACE inhibitors in patients who had myocardial infarction, cardiac surgeons are likely to see more patients who have had long-term ACE inhibitor therapy. Carefully organized clinical studies will need to be performed to determine whether preoperative treatment with ACE inhibitors is associated with increased postoperative morbidity. Prospective, randomized clinical studies are also being planned to determine whether the favorable effects of ACE inhibitors seen in our experimental model will result in decreased morbidity and mortality in patients undergoing urgent and emergent coronary revascularization after myocardial infarction.

References

1. Lazar H.L., Volpe C., Bao Y., Rivers S., Vita J.A., Keaney J.F., Jr Beneficial effects of angiotensin-converting enzyme inhibitors during acute revascularization. Ann Thorac Surg 1998;66:487-492.[Abstract/Free Full Text]
2. Piana R.N., Wang S.Y., Friedman M., Sellke F.W. Angiotensin-converting enzyme inhibition preserves endothelium-dependent coronary microvascular responses during short-term ischemia-reperfusion. Circulation 1996;93:544-551.[Abstract/Free Full Text]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Harold L. Lazar Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lazar, H. L. Search for Related Content PubMed Articles by Lazar, H. L.