Poursuite versus arrêt des antagonistes du système rénine-angiotensine-aldostérone en préopératoire de chirurgie non cardiaque : Revue systématique et méta-analyse
DOI :
https://doi.org/10.62438/tunismed.v103i9.6236Mots-clés :
Antagonistes des récepteurs aux angiotensines, inhibiteurs de l'enzyme de conversion de l'angiotensine, chirurgie non cardiaque, hypotension peropératoireRésumé
Introduction : La nécessité de poursuivre ou d’interrompre le traitement par antagonistes des récepteurs de l’angiotensine (ARA) et inhibiteurs de l’enzyme de conversion de l’angiotensine (IEC) avant une intervention chirurgicale non cardiaque afin de réduire la morbidité péri-opératoire reste incertaine. Cette revue systématique et méta-analyse visait à analyser les conséquences de la poursuite du traitement par ARA ou IEC sur l’incidence de l’hypotension peropératoire et des complications postopératoires.
Méthodes : Cette revue systématique et méta-analyse a suivi les recommandations PRISMA 2020 et a été enregistrée dans la base de données PROSPERO. Nous avons effectué une recherche exhaustive dans plusieurs bases de données bibliographiques afin d’identifier des études comparant la poursuite ou l’arrêt du traitement par ARA avant une intervention chirurgicale non cardiaque. Le critère de jugement principal était l’incidence de l’hypotension peropératoire, tandis que les critères d’évaluation secondaires étaient l’utilisation peropératoire de l’agent vasoactif, l’incidence de l’hypotension sévère, l’hypertension peropératoire et postopératoire, l’incidence de l’insuffisance rénale aiguë (IRA), la mortalité toutes causes confondues à 30 jours postopératoires et l’incidence des événements cardio-cérébraux majeurs (ECCM).
Résultats : Cinq essais contrôlés randomisés, trois essais contrôlés non randomisés et quatre études cas-témoins rétrospectives ont été inclus, portant sur 50 184 patients. Une méta-analyse a révélé que la poursuite du traitement par IEC ou ARA II avant la chirurgie augmentait l’incidence d’hypotension peropératoire (OR = 1,96, IC à 95 % [1,30, 2,96], p = 0,001). L’hétérogénéité était importante entre les études, mais était significativement réduite dans les analyses de sous-groupes. De plus, l’utilisation d’agents vasoactifs et l’incidence d’hypotension sévère étaient significativement plus élevées dans le groupe poursuivant le traitement. Aucune différence significative n’a été observée concernant l’hypertension peropératoire et l’incidence d’IRA et d’ECCM à 30 jours après l’opération.
Conclusions : La poursuite du traitement par IEC ou ARA II avant une chirurgie non cardiaque augmente l’incidence d’hypotension peropératoire, sans réduire l’incidence d’IRA et d’ECCM en postopératoire. Des recherches supplémentaires sont nécessaires pour explorer la prise en charge périopératoire appropriée des IEC et des ARA II.
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