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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
ACC/AHA/HRS guideline for the evaluation and management of syncope (July 2017)
In 2017 the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) published guidelines on evaluation and management of patients with syncope, the first major new syncope guidelines in eight years . The guidelines present an approach to the evaluation and management of patients with syncope that is consistent with the approach advocated by UpToDate experts. Both UpToDate and the ACC/AHA/HRS guidelines emphasize the importance of a detailed medical history, physical examination, and review of an electrocardiogram as the initial evaluation in all patients. An echocardiogram should be performed in patients with known or suspected structural heart disease, with selected additional testing directed by the results of the initial evaluation. (See "Syncope in adults: Clinical manifestations and diagnostic evaluation", section on 'Initial evaluation'.)
Management of dabigatran in the periprocedural period prior to catheter ablation for AF (June 2017)
Most patients scheduled to undergo catheter ablation for atrial fibrillation (AF) receive effective oral anticoagulation weeks before the procedure. When warfarin is used as the anticoagulant, it is given without interruption up to the procedure. The newer oral anticoagulants (NOAC), such as dabigatran, are most often held the day prior to the procedure. In the RE-CIRCUIT trial, 704 patients scheduled for catheter ablation were randomly assigned to take dabigatran 150 mg twice daily (without interruption prior to catheter ablation) or warfarin (target INR 2.0-3.0) for 4 to 8 weeks prior to the procedure . There were significantly fewer episodes of major bleeding in the dabigatran group but no significant difference in the rate of thromboembolism. UpToDate authors continue to advise discontinuing dabigatran before catheter ablation, but suggest that uninterrupted dabigatran may be reasonable for the patient who is at very high risk of a periprocedural stroke. (See "Catheter ablation to prevent recurrent atrial fibrillation: Anticoagulation", section on 'Choice of anticoagulant'.)
MRI in patients with pacemakers or implantable cardioverter-defibrillators (March 2017)
Potential risks of magnetic resonance imaging (MRI) in patients with permanent pacemakers or implantable cardioverter-defibrillators (ICDs) include programming changes, pacing abnormalities, and induced currents in lead wires. In a prospective multicenter trial, 1500 nonthoracic MRI examinations were performed in a 1.5T magnet on patients with a non-MRI-conditional pacemaker or ICD that had been programmed according to a standardized protocol; no device or lead failures were observed . While these reports are reassuring, the presence of a pacemaker or ICD is still generally considered a strong relative contraindication to routine MRI. (See "Principles of magnetic resonance imaging", section on 'Permanent pacemakers and implantable cardioverter-defibrillators'.)
Risk of sudden cardiac death in patients with HCM and LV apical aneurysms (February 2017)
Patients with hypertrophic cardiomyopathy (HCM) have an increased risk of death from several causes, including ventricular tachycardia (VT) resulting in sudden cardiac death (SCD). Clinical evaluation for five established major risk factors (ie, syncope, nonsustained VT, massive left ventricular hypertrophy, abnormal blood pressure response to exercise, and family history of SCD) helps to identify patients for whom an implantable cardioverter defibrillator (ICD) may be warranted for primary prevention of SCD. A recent paper supports an additional criterion for ICD placement . In this study, patients with HCM and a left ventricular (LV) apical aneurysm, compared with patients without an LV apical aneurysm, had five times the risk of VT and SCD. Patients with HCM and an LV apical aneurysm should receive strong consideration for ICD placement, as well as radiofrequency ablation for recurrent VT, if present. (See "Hypertrophic cardiomyopathy: Assessment and management of ventricular arrhythmias and sudden cardiac death risk", section on 'Established high-risk clinical features'.)
Emergency coronary catheterization following sudden cardiac arrest (February 2017)
Emergency coronary catheterization is indicated for patients who sustain sudden cardiac arrest (SCA) and manifest signs of an acute coronary syndrome (ACS), such as ST elevation on their electrocardiogram. However, whether coronary catheterization should be performed in SCA patients without such signs remains controversial. A meta-analysis of 11 heterogeneous, retrospective studies involving several thousand patients found that over 30 percent of post-arrest patients with no ST elevation had acute coronary artery occlusions regardless of their presenting rhythm . While randomized trials are needed to address this question, we believe it is reasonable to perform coronary catheterization in SCA patients without discrete signs of ACS, provided resources to do so are available. (See "Post-cardiac arrest management in adults", section on 'Coronary revascularization'.)
CORONARY HEART DISEASE, ACUTE
Timing of coronary angiography in patients with NSTEACS (August 2017)
Unlike patients with ST-elevation myocardial infarction who should undergo coronary angiography and revascularization within a few hours of symptom onset, the optimal timing of angiography in patients with non-ST elevation acute coronary syndromes (NSTEACS) is not known. A 2017 meta-analysis evaluated mortality in eight randomized trials that compared early to delayed invasive treatment . There was no difference in mortality between the two strategies. However, subgroup analysis suggested benefit from early intervention in patients at high risk. We generally perform coronary angiography in most NSTEACS patients within 24 hours of presentation. (See "Coronary angiography and revascularization for unstable angina or non-ST elevation acute myocardial infarction", section on 'Timing'.)
Rapid aspirin desensitization in patients with acute coronary syndrome (April 2017)
There are well-established protocols for elective desensitization to aspirin, but fewer studies of approaches in patients needing urgent treatment. In a multicenter observational study of 330 consecutive patients with acute coronary syndrome and past hypersensitivity reactions to nonsteroidal anti-inflammatory drugs (NSAIDs), 95 percent were successfully desensitized to low-dose aspirin using a protocol that could be completed within six hours . The procedure was aborted in 5 percent because symptoms developed during the protocol. While useful, we prefer our own approach because it does not exclude patients who react during the protocol. (See "Diagnostic challenge and desensitization protocols for NSAID reactions", section on 'Our approach'.)
Trimethylamine-N-oxide (TMAO) levels and prognosis in patients with acute coronary syndrome (April 2017)
Trimethylamine-N-oxide (TMAO), produced through intestinal microbial metabolism of dietary lecithin, appears to contribute to the development of atherosclerosis. Elevated TMAO levels may be of prognostic significance as well. In a cohort of 530 consecutive patients with suspected acute coronary syndrome (ACS), elevated TMAO levels at presentation were associated with greater risk of major adverse cardiac events (myocardial infarction, stroke, revascularization, and death) at 30 days and six months and an increased risk of mortality at seven years . TMAO levels vary significantly according to diet as well as kidney and liver function, so additional studies are needed to confirm their role as a prognostic marker in patients with ACS. (See "Overview of possible risk factors for cardiovascular disease", section on 'Trimethylamine-N-oxide (TMAO)'.)
Complete revascularization for STEMI patients undergoing primary PCI (February 2017, Modified April 2017)
Several studies have evaluated the management of significant nonculprit coronary lesions in patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI).
●The Compare-Acute trial randomly assigned 885 patients to undergo complete revascularization of noninfarct-related coronary arteries or no revascularization . Fractional flow reserve (FFR) was measured in both groups and nonculprit PCI was usually performed within minutes of primary PCI in the revascularization group. The primary composite end point (death from any cause, nonfatal MI, (repeat) revascularization, and cerebrovascular events at 12 months) occurred less often with complete revascularization, driven principally by many fewer revascularizations.
●A 2017 network meta-analysis, published before Compare-Acute, compared four revascularization strategies: complete revascularization at the index procedure; complete revascularization prior to discharge; complete revascularization within a few weeks after discharge; and culprit-only PCI . Major adverse cardiovascular events occurred less frequently in patients who underwent complete revascularization, performed at any of the time intervals, compared with culprit-only PCI. The outcome was mainly attributable to a lower rate of urgent revascularization.
These studies support our suggestion to perform FFR-guided PCI of nonculprit lesions prior to discharge in most cases and to do so at the time of primary PCI in many. (See "Primary percutaneous coronary intervention in acute ST-elevation myocardial infarction: Non-culprit lesions", section on 'Management approaches to non-culprit lesions'.)
Switching MI patients from ticagrelor to clopidogrel (March 2017)
The potent platelet P2Y12 receptor blocker ticagrelor, rather than clopidogrel, is initiated in hospital for many patients with myocardial infarction. However, some of these individuals will need to switch to clopidogrel either before or after hospital discharge. A randomized trial compared the pharmacodynamic effects of switching from ticagrelor to clopidogrel with or without a loading dose of clopidogrel . The study identified a period of time after the first dose of clopidogrel (12 hours after the last dose of ticagrelor) when there was greater antiplatelet effect with the loading dose than without. Based on this pharmacodynamic study, we give a clopidogrel loading dose of 600 mg when switching from ticagrelor to clopidogrel therapy. (See "Antiplatelet agents in acute ST elevation myocardial infarction", section on 'Switching from a P2Y12 agent to clopidogrel' and "Antiplatelet agents in acute non-ST elevation acute coronary syndromes", section on 'Switching from a P2Y12 agent to clopidogrel'.)
CORONARY HEART DISEASE, STABLE
Fluctuations in body weight and risk of CHD (April 2017)
While obesity is associated with an increased risk for coronary heart disease (CHD) and sustained weight loss reduces the risk of CHD, the effects of frequent weight gain and loss on CHD risk are unknown. A post hoc analysis of data from a secondary prevention statin study involving over 9000 patients with established CHD and LDL cholesterol below 130 mg/dL (3.4 mmol/L) found that patients in the highest quintile of weight fluctuation (mean variability of 3.9 kg) had significantly higher risks of any CHD event, any cardiovascular disease event, and total mortality, compared with those in the quintile with the lowest weight variation, and that risk increased with each standard deviation change in magnitude of weight fluctuation . These findings suggest that frequent cycles of weight gain and weight loss are associated with an increased risk of CHD and cardiovascular disease events, with greatest magnitude of risk among those who were overweight or obese at baseline. (See "Overview of the risk equivalents and established risk factors for cardiovascular disease", section on 'Obesity'.)
Rivaroxaban plus P2Y12 inhibitor in patients with atrial fibrillation who undergo coronary stenting (March 2017)
The optimal antithrombotic regimen for patients with atrial fibrillation (AF) who undergo coronary artery stenting is not known. Patients may require a period of triple antithrombotic therapy with an oral anticoagulant, aspirin, and a P2Y12 inhibitor (usually clopidogrel). In most of the studies that have evaluated triple therapy, warfarin was the anticoagulant rather than a non-vitamin K antagonist oral anticoagulant. In addition, bleeding complications have led to the evaluation of antithrombotic therapy with two agents. The PIONEER AF-PCI trial compared three regimens in over 2000 patients: low-dose rivaroxaban plus a P2Y12 inhibitor for 12 months; very-low-dose rivaroxaban plus dual antiplatelet therapy (DAPT); or standard therapy with a dose-adjusted vitamin K antagonist plus DAPT . Clinically significant bleeding occurred less often in the two groups receiving rivaroxaban; efficacy was similar in the three groups at 12 months. This study supports the use of rivaroxaban as a reasonable alternative to warfarin, and the use of two rather than three drugs in patients who are candidates for triple therapy. The very-low-dose of rivaroxaban used in the trial is not approved for use in this setting. (See "Antithrombotic therapy after coronary stenting in patients receiving long-term anticoagulation", section on 'Alternatives to warfarin'.)
Declining rate of sudden death in heart failure with reduced ejection fraction (July 2017)
Evidence-based medical therapy for heart failure with reduced ejection fraction (HFrEF) reduces both overall mortality rates and risk of sudden death. The trend in risk of sudden death was examined by an analysis of data from over 40,000 patients with HFrEF enrolled in 12 clinical trials of medical therapy with study periods spanning 1995 through 2014 . There was a significant decline in the rate of sudden death across the trials. The cumulative incidence of sudden death at 90 days after trial randomization was 2.4 percent in the earliest trial and 1.0 percent in the most recent trial. (See "Prognosis of heart failure", section on 'Cause of death'.)
Ularitide does not improve outcomes for acute heart failure (May 2017)
Early vasodilator therapy has been proposed as a means of improving outcomes for acute heart failure. However, in a randomized trial comparing a 48-hour infusion of ularitide (a synthetic analogue of the renal vasodilatory peptide urodilatin) with placebo in over 2000 patients presenting with acute heart failure, ularitide led to greater reductions in systolic blood pressure but no difference in clinical outcomes at 48 hours based upon a composite endpoint . Cardiovascular mortality rates at 15 months were similar for both groups. Thus, ularitide caused short-term hemodynamic effects but did not improve clinical outcomes. (See "Treatment of acute decompensated heart failure: Components of therapy", section on 'Ularitide'.)
Adaptive servoventilation in adults with central sleep apnea and heart failure (April 2017)
A previous randomized trial (SERVE-HF) found that adaptive servoventilation (ASV), a modified method of positive airway pressure ventilation, increased cardiovascular mortality in patients with central sleep apnea (CSA) due to symptomatic heart failure with reduced ejection fraction. In the CAT-HF trial, 126 hospitalized patients with heart failure and moderate-to-severe CSA were randomly assigned to ASV plus optimized medical therapy or medical therapy alone . While the trial showed no difference between the groups in a combined endpoint (death, cardiovascular hospitalizations, and timed walk distance), the confidence intervals were wide and there was a suggestion of increased harm in the ASV group (HR 1.06, 95% CI 0.75-1.51). The trial was stopped early, in part due to results of SERVE-HF. Although this limits interpretation of the CAT-HF results, we continue to recommend against use of ASV in patients with CSA and heart failure with reduced ejection fraction. (See "Sleep-disordered breathing in heart failure", section on 'Adaptive servoventilation' and "Central sleep apnea: Treatment", section on 'Patients with ejection fraction ≤45 percent'.)
Targeting natriuretic peptide level in treatment of acute heart failure (February 2017)
Since natriuretic peptides have relatively short half-lives, it has been postulated that serial measurements might help guide management of acute heart failure. A systematic review found low-quality evidence supporting an association between achievement of natriuretic predischarge thresholds and reduced acute heart failure mortality and readmission . However, a randomized trial studying the effect of treating to a target natriuretic peptide level found no improvement in outcomes with a natriuretic peptide-guided strategy, although a reduction in natriuretic peptide during hospitalization was associated with better outcomes [18,19]. Thus, natriuretic peptide levels have prognostic value in patients with acute heart failure, but evidence does not support targeting lower levels as a means of improving outcomes. (See "Natriuretic peptide measurement in heart failure", section on 'Acute HF'.)
Methamphetamine use and cardiomyopathy (June 2017)
Cardiovascular complications, particularly cardiomyopathy, are the leading causes of death among individuals using methamphetamine, yet there are few data on cardiomyopathy outcomes among methamphetamine users. In a study of 30 methamphetamine users with reduced left ventricular ejection fraction (LVEF) who were followed for a mean of nearly three years, cessation of use compared with continuing use was associated with better cardiac function and a trend toward reduced cardiac symptoms . The extent of myocardial fibrosis was associated with the duration of methamphetamine use and may serve as a marker of irreversible ventricular changes. (See "Methamphetamine use disorder: Epidemiology, clinical manifestations, course, assessment, and diagnosis", section on 'Cardiovascular disease'.)
Risk of thromboembolism in patients with HCM and LV apical aneurysm (February 2017)
Although subsets of patients with hypertrophic cardiomyopathy (HCM) and a risk factor for thromboembolism (eg, atrial fibrillation, left ventricular [LV] aneurysm) are at high risk for thromboembolic events, they have generally been excluded from studies of thromboembolism prophylaxis. Among a cohort of patients with HCM and LV apical aneurysm who were in normal sinus rhythm, the thromboembolic event rate without anticoagulation exceeded 1 percent per year, regardless of the size of the aneurysm . For patients with HCM and LV apical aneurysm, we suggest long-term oral anticoagulation, rather than aspirin or no anticoagulation, to reduce the risk of thromboembolism. (See "Hypertrophic cardiomyopathy: Medical therapy", section on 'Thromboembolism prophylaxis'.)
Small interfering RNA molecules to lower PCSK9 and LDL-C (April 2017)
The profound ability of monoclonal antibodies to proprotein convertase subtilisin/kexin type 9 (PCSK9) to lower low-density lipoprotein-cholesterol (LDL-C) has prompted research into other ways of lowering PCSK9. Small interfering RNA molecules (siRNA) offer the potential to lower PCSK9 at a decreased dose frequency compared with monoclonal antibodies. One siRNA inhibitor of PCSK9 synthesis (inclisiran) has undergone phase 2 (dose-finding) evaluation. A randomized trial compared several doses of inclisiran with placebo in 501 patients at high cardiovascular disease risk receiving maximal possible dose of statin therapy . At the highest dose, inclisiran reduced LDL-C by approximately 50 percent from baseline and there were no serious adverse events. (See "PCSK9 inhibitors: Pharmacology, adverse effects, and use", section on 'Ongoing investigation'.)
Instantaneous wave-free ratio versus fractional flow reserve for coronary artery stenosis evaluation (May 2017)
For patients with coronary artery stenoses of intermediate severity, measurement of fractional flow reserve (FFR) with adenosine-induced hyperemia may be used to assess the functional significance of the lesion. However, patients often complain of significant chest pain, attributable to the adenosine, which limits its use. Two randomized non-inferiority trials have compared clinical outcomes for low-risk patients evaluated by FFR with a newer method, instantaneous wave-free ratio (iFR), which does not require adenosine [22,23]. The rate of a composite clinical outcome (death, myocardial infarction, or unplanned revascularization within 12 months) was similar in both groups, but the frequency of adenosine-induced chest discomfort was less with iFR and the duration of the procedure was shorter. We choose either iFR or FFR for evaluation of intermediate lesions. (See "Clinical use of coronary artery pressure flow measurements", section on 'iFR compared with FFR'.)
Increased risk of stent thrombosis with bioresorbable intracoronary scaffolds (April 2017)
Bioresorbable intracoronary stents were developed to overcome limitations of metallic intracoronary stents, such as the inability to subsequently place a bypass graft. However, early trials of these new stents have suggested an increased risk of stent thrombosis compared with commonly used drug-eluting stents. In a preliminary analysis of the AIDA trial, which randomly assigned over 1800 patients to a bioresorbable or metallic stent, there was an increased risk of definite or probable device thrombosis in the scaffold group at two years and there was no evidence of benefit . We do not advocate the routine use of bioresorbable intracoronary drug-eluting stents. (See "Bioresorbable polymer or scaffold drug-eluting coronary artery stents", section on 'Bioresorbable stents or scaffolds'.)
Exercise-based rehabilitation in heart transplant recipients (June 2017)
Most cardiac transplant recipients experience improvement in functional capacity post transplant compared with their preoperative condition, but exercise capacity generally remains below normal. The effect of exercise-based rehabilitation post cardiac transplantation was assessed by a systematic review of 10 randomized controlled trials with a total of 300 participants and median 12 weeks of follow-up . Exercise-based rehabilitation improved exercise capacity compared with no exercise but had no effect on health-related quality of life (HRQoL). We continue to recommend exercise-based cardiac rehabilitation for cardiac transplant recipients, although further studies are needed to determine its long-term effects. (See "Rehabilitation after cardiac transplantation", section on 'Exercise capacity and rehabilitation post-transplantation'.)
VALVULAR HEART DISEASE
Embolic protection devices during transcatheter aortic valve implantation (April 2017)
Transcatheter aortic valve implantation (TAVI) has an evolving role as an alternative to surgical aortic valve replacement in treating patients with symptomatic severe aortic stenosis. However, TAVI is associated with an increased risk of stroke and risk of subclinical ischemic brain lesions on magnetic resonance imaging (MRI). Embolic protection devices (EPDs) have been studied as potential means of reducing this risk of stroke. A meta-analysis included 16 studies involving 1170 patients who underwent TAVI, the majority treated with EPD . Analyses comparing EPD versus no EPD strategies could not confirm or exclude differences in clinically evident stroke or mortality at 30 days. While there was no significant difference in numbers of new lesions, use of EPD was associated with a significantly smaller total volume of ischemic lesions. Further study is needed to determine whether EPDs can improve clinical outcomes. (See "Transcatheter aortic valve implantation: Complications", section on 'Stroke and subclinical brain injury'.)
Subclinical bioprosthetic leaflet thrombosis (March 2017)
The prevalence and clinical significance of subclinical leaflet thrombosis of bioprosthetic aortic valves has not been established. A four-dimensional computed tomography (CT) imaging protocol to detect subclinical leaflet thrombosis was performed in over 900 patients with bioprosthetic valves at varying intervals after transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) . Subclinical leaflet thrombosis was more common with transcatheter valves than with surgical valves (13 versus 4 percent) and was more frequent with dual antiplatelet therapy compared with anticoagulation. Subclinical leaflet thrombosis was associated with an increased frequency of elevated aortic valve gradients and increased rates of transient ischemic attacks (TIAs) or strokes. Clinical trials are underway to determine the safety and efficacy of anticoagulation compared with the current standard of antiplatelet therapy following TAVI. (See "Transcatheter aortic valve implantation: Complications", section on 'Valve thrombosis'.)
Transcatheter aortic valve implantation versus surgical aortic valve replacement in patients at intermediate surgical risk (March 2017)
The role of transcatheter aortic valve implantation (TAVI) in patients with symptomatic severe aortic stenosis with intermediate surgical risk has not been established. A randomized trial in over 1700 patients compared outcomes following TAVI (with a self-expanding bioprosthesis; over 90 percent via transfemoral access) versus surgical aortic valve placement (SAVR) . The incidence of the primary composite end point of death from any cause or disabling stroke at 24 months was similar in the two groups. Rates of atrial fibrillation, transfusion, and acute kidney injury were more frequent in the SAVR group, while major vascular complications, permanent pacemaker implantation, and paravalvular aortic regurgitation were more common in the TAVI group. These results add to prior randomized trials showing that transfemoral TAVI is a noninferior alternative to SAVR in intermediate surgical risk patients with symptomatic severe aortic stenosis. (See "Choice of therapy for symptomatic severe aortic stenosis", section on 'In intermediate-risk patients'.)
Confirmatory data on idarucizumab for dabigatran reversal (July 2017)
Idarucizumab (pronounced "I-dare-you-cizumab") is a monoclonal antibody fragment against dabigatran that can reverse the anticoagulant effect within minutes. A preliminary report suggested good efficacy in patients with dabigatran-associated bleeding or those undergoing emergency surgery. In a new report of over 500 patients treated with idarucizumab, most had cessation of bleeding or underwent surgery without abnormal bleeding . We continue to suggest idarucizumab for clinically significant bleeding or emergency surgery in patients on dabigatran with a history or laboratory testing that suggest they are actively anticoagulated. (See "Management of bleeding in patients receiving direct oral anticoagulants", section on 'Dabigatran reversal'.)
Radiation for nonmetastastic breast cancer and cardiovascular risk (June 2017)
Many women treated for nonmetastatic breast cancer receive radiation therapy after surgical resection. In a meta-analysis of 39 studies involving almost 1.2 million patients with breast cancer, the risk of coronary artery disease and cardiac death was somewhat increased (relative risk 1.3 and 1.38, respectively) for those who received radiotherapy relative to those who did not . However, absolute risks for these complications were low (76 and 126 cases, respectively, per 100,000 person-years). For appropriately selected patients, adjuvant radiation remains a safe and effective treatment for nonmetastatic breast cancer. (See "Cardiotoxicity of radiation therapy for breast cancer and other malignancies", section on 'Meta-analyses and randomized trials'.)
Routine prophylactic antibiotics do not improve clinically important outcomes in survivors of out-of-hospital cardiac arrest (April 2017)
Many survivors of out-of-hospital cardiac arrest (OHCA) go on to develop pneumonia, but the value of prophylactic antibiotics is unproven. In a single-center clinical trial involving 60 comatose OHCA patients without obvious evidence of tracheobronchial aspiration on admission, random assignment to prophylactic antibiotics versus clinically-driven antibiotic therapy reduced the number of positive broncho-alveolar lavage cultures on hospital day 3, but did not improve survival or other patient-important outcomes . We do not suggest routine prophylactic treatment with antibiotics in these patients. (See "Post-cardiac arrest management in adults", section on 'Antibiotic therapy and prophylaxis'.)
Withholding ACE-I/ARB prior to noncardiac surgery (April 2017)
In many patients undergoing noncardiac surgery, angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) is withheld prior to the procedure out of a concern for the potential of perioperative hypotension. In a prospective cohort analysis of over 3000 patients undergoing noncardiac surgery taking these medications, the composite risk of all-cause death, stroke, or myocardial injury and the risk of intraoperative hypotension was lower among those in whom ACE-I/ARB was withheld . We omit these during the 24 hours prior to surgery in many patients. (See "Management of cardiac risk for noncardiac surgery", section on 'ACE inhibitor or ARB'.)
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