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The Effect of Renin-Angiotensin System Blockade on Abdominal Aortic Aneurysm Growth, Rupture, and Perioperative Outcomes: A Systematic Review and Meta-Analysis

Journal of Vascular Surgery - DOI: http://dx.doi.org/10.1016/j.jvs.2017.07.041


Objective: The purpose of this study was to summarize the literature regarding the effects of angiotensin-converting enzyme inhibitor (ACEi) and angiotensin receptor blocker (ARB) treatment on human abdominal aortic aneurysm (AAA) growth, rupture, and perioperative mortality.

Methods: We conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our review protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO 2016: CRD42016054082). We searched MEDLINE, Embase, and the Cochrane CENTRAL databases from inception to 2017 for studies examining the effects of ACEi or ARB treatment on AAA growth, rupture, or perioperative mortality. Review, abstraction, and quality assessment were conducted in duplicate, and a third author resolved discrepancies. We assessed study quality using the Cochrane and Newcastle-Ottawa scales. We used random-effects models to calculate pooled mean differences and odds ratios (OR) with 95% confidence intervals. Heterogeneity was quantified using the I2 statistic.

Results: Our search yielded 525 articles. One randomized and eight observational studies involving 35,565 patients were included. Inter-rater agreement was excellent (κ = 0.78), and risk of bias was low to moderate. All studies investigated ACEi; three studies investigated ARBs; and two studies included a composite ACEi or ARB group. Four studies assessed rupture and 30-day mortality, and five studies assessed AAA growth. There was no difference in AAA growth rate between ACEi and control (mean difference, 0.11 mm/y; 95% confidence interval [CI], −0.21 to 0.42; P = .51; I2 = 42%; Fig 1) or ARB vs control (mean difference, −0.57; 95% CI, −1.33 to 0.18; P = .14; I2 = 0%). No protective effect of ACEi was demonstrated for AAA rupture (OR, 0.90; 95% CI, 0.73-1.12; P = .36; I2 = 85%; Fig 2).

Conclusions: ACEi treatment does not affect AAA growth or rupture rates. The small number of retrospective studies and limited long-term follow-up preclude the dismissal of ACEi or ARB pharmacotherapy for AAA. More prospective, long-term research is needed to determine the effect of renin-angiotensin system blockade on AAA growth, rupture, and perioperative mortality.



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