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Effects of withdrawing vs continuing renin-angiotensin blockers on incidence of acute kidney injury in patients with renal insufficiency undergoing cardiac catheterization: Results from the Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker and Contrast Induced Nephropathy in Patients Receiving Cardiac Catheterization (CAPTAIN) trial.
Am Heart J 2015; 170(1):110-6AH

Abstract

BACKGROUND

It is unclear if holding angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) prior to coronary angiography reduces contrast-induced acute kidney injury (AKI). We undertook a randomized trial to investigate the effect of holding ACEI/ARB therapy prior to coronary angiography on the incidence of AKI.

METHODS

We randomly assigned 208 patients with moderate renal insufficiency (creatinine ≥ 1.7mg/dL within 3 months and/or documented creatinine ≥ 1.5mg/dL within 1 week before cardiac catheterization) to hold ACEI/ARB ≥24 hours preprocedure or continue ACEI/ARB. The primary outcome was the incidence of AKI defined as an absolute rise in serum creatinine of ≥0.5mg/dL from baseline and/or a relative rise in serum creatinine of ≥25% compared with baseline measured at 48 to 96 hours postcardiac catheterization.

RESULTS

All patients were taking an ACEI (72.1%) or ARB (27.9%) prior to randomization. At 48 to 96 hours, the primary outcome occurred in 18.4% of patients who continued ACEI/ARB compared with 10.9% of the patients who held ACEI/ARB (hazard ratio 0.59, 95% CI 0.30-1.19, P = .16). In a prespecified secondary outcome, there was a lower rise in mean serum creatinine after the procedure in patients who held ACEI/ARB (0.3 ± 0.5 vs 0.1 ± 0.3mg/dL, P = .03). The clinical composite of death, myocardial infarction, ischemic stroke, congestive heart failure, rehospitalization for cardiovascular cause, or need for dialysis preprocedure occurred in 3.9% who continued ACEI/ARB compared with 0% who held the ACEI/ARB (hazard ratio 0.11, 95% CI 0.01-2.96, P = .06).

CONCLUSION

In this pilot study of patients with moderate renal insufficiency undergoing cardiac catheterization, with-holding ACEI/ARB resulted in a non-significant reduction in contrast-induced AKI and a significant reduction in post-procedural rise of creatinine. This low cost intervention could be considered when referring a patient for cardiac catheterization.

Authors+Show Affiliations

Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada.Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada.Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada.Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada.Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada.Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada.Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada. Electronic address: smehta@mcmaster.ca.No affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Randomized Controlled Trial

Language

eng

PubMed ID

26093871

Citation

Bainey, Kevin R., et al. "Effects of Withdrawing Vs Continuing Renin-angiotensin Blockers On Incidence of Acute Kidney Injury in Patients With Renal Insufficiency Undergoing Cardiac Catheterization: Results From the Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker and Contrast Induced Nephropathy in Patients Receiving Cardiac Catheterization (CAPTAIN) Trial." American Heart Journal, vol. 170, no. 1, 2015, pp. 110-6.
Bainey KR, Rahim S, Etherington K, et al. Effects of withdrawing vs continuing renin-angiotensin blockers on incidence of acute kidney injury in patients with renal insufficiency undergoing cardiac catheterization: Results from the Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker and Contrast Induced Nephropathy in Patients Receiving Cardiac Catheterization (CAPTAIN) trial. Am Heart J. 2015;170(1):110-6.
Bainey, K. R., Rahim, S., Etherington, K., Rokoss, M. L., Natarajan, M. K., Velianou, J. L., ... Mehta, S. R. (2015). Effects of withdrawing vs continuing renin-angiotensin blockers on incidence of acute kidney injury in patients with renal insufficiency undergoing cardiac catheterization: Results from the Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker and Contrast Induced Nephropathy in Patients Receiving Cardiac Catheterization (CAPTAIN) trial. American Heart Journal, 170(1), pp. 110-6. doi:10.1016/j.ahj.2015.04.019.
Bainey KR, et al. Effects of Withdrawing Vs Continuing Renin-angiotensin Blockers On Incidence of Acute Kidney Injury in Patients With Renal Insufficiency Undergoing Cardiac Catheterization: Results From the Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker and Contrast Induced Nephropathy in Patients Receiving Cardiac Catheterization (CAPTAIN) Trial. Am Heart J. 2015;170(1):110-6. PubMed PMID: 26093871.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Effects of withdrawing vs continuing renin-angiotensin blockers on incidence of acute kidney injury in patients with renal insufficiency undergoing cardiac catheterization: Results from the Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker and Contrast Induced Nephropathy in Patients Receiving Cardiac Catheterization (CAPTAIN) trial. AU - Bainey,Kevin R, AU - Rahim,Sherali, AU - Etherington,Krystal, AU - Rokoss,Michael L, AU - Natarajan,Madhu K, AU - Velianou,James L, AU - Brons,Sonya, AU - Mehta,Shamir R, AU - ,, Y1 - 2015/04/18/ PY - 2014/09/10/received PY - 2015/04/15/accepted PY - 2015/6/22/entrez PY - 2015/6/22/pubmed PY - 2015/9/1/medline SP - 110 EP - 6 JF - American heart journal JO - Am. Heart J. VL - 170 IS - 1 N2 - BACKGROUND: It is unclear if holding angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) prior to coronary angiography reduces contrast-induced acute kidney injury (AKI). We undertook a randomized trial to investigate the effect of holding ACEI/ARB therapy prior to coronary angiography on the incidence of AKI. METHODS: We randomly assigned 208 patients with moderate renal insufficiency (creatinine ≥ 1.7mg/dL within 3 months and/or documented creatinine ≥ 1.5mg/dL within 1 week before cardiac catheterization) to hold ACEI/ARB ≥24 hours preprocedure or continue ACEI/ARB. The primary outcome was the incidence of AKI defined as an absolute rise in serum creatinine of ≥0.5mg/dL from baseline and/or a relative rise in serum creatinine of ≥25% compared with baseline measured at 48 to 96 hours postcardiac catheterization. RESULTS: All patients were taking an ACEI (72.1%) or ARB (27.9%) prior to randomization. At 48 to 96 hours, the primary outcome occurred in 18.4% of patients who continued ACEI/ARB compared with 10.9% of the patients who held ACEI/ARB (hazard ratio 0.59, 95% CI 0.30-1.19, P = .16). In a prespecified secondary outcome, there was a lower rise in mean serum creatinine after the procedure in patients who held ACEI/ARB (0.3 ± 0.5 vs 0.1 ± 0.3mg/dL, P = .03). The clinical composite of death, myocardial infarction, ischemic stroke, congestive heart failure, rehospitalization for cardiovascular cause, or need for dialysis preprocedure occurred in 3.9% who continued ACEI/ARB compared with 0% who held the ACEI/ARB (hazard ratio 0.11, 95% CI 0.01-2.96, P = .06). CONCLUSION: In this pilot study of patients with moderate renal insufficiency undergoing cardiac catheterization, with-holding ACEI/ARB resulted in a non-significant reduction in contrast-induced AKI and a significant reduction in post-procedural rise of creatinine. This low cost intervention could be considered when referring a patient for cardiac catheterization. SN - 1097-6744 UR - https://www.unboundmedicine.com/medline/citation/26093871/Effects_of_withdrawing_vs_continuing_renin_angiotensin_blockers_on_incidence_of_acute_kidney_injury_in_patients_with_renal_insufficiency_undergoing_cardiac_catheterization:_Results_from_the_Angiotensin_Converting_Enzyme_Inhibitor/Angiotensin_Receptor_Blocker_and_Contrast_Induced_Nephropathy_in_Patients_Receiving_Cardiac_Catheterization__CAPTAIN__trial_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0002-8703(15)00252-5 DB - PRIME DP - Unbound Medicine ER -