Evidence map›Paper›PMID 37935833›Full record

Trial reportEuropean heart journal2024

Discontinuation vs. continuation of renin-angiotensin system inhibition before non-cardiac surgery: the SPACE trial.

Gareth L Ackland, Akshaykumar Patel, Tom E F Abbott, Salma Begum, Priyanthi Dias, David R Crane, Sameer Somanath, Alexander Middleditch, Stuart Cleland, Ana Gutierrez Del Arroyo and 3 more

Open access · hybridAbstract readRandomized Controlled Trial
PubMed Full text at PMC Publisher
In one paragraph

Trial report in European heart journal, 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 26 papers, 5 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
26citing papers in PubMed, 5 pooled it
13.6field-weighted citation impact, top 1% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

26 citing papers in PubMed, 5 syntheses or guidelines pooled it, 62 citations in OpenAlex.

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  15. Acute heart failure in non-cardiac surgery.European heart journal · 2025
    Review
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4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

13 authors at 5 institutions in 1 country.

Gareth L AcklandTranslational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.ORCID 0000-0003-0565-5164
Akshaykumar PatelTranslational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.
Tom E F AbbottTranslational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.
Salma BegumTranslational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.
Priyanthi DiasTranslational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.
David R CraneTranslational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.
Sameer SomanathCounty Durham and Darlington NHS Foundation Trust, Darlington, UK.
Alexander MiddleditchUniversity Hospitals Bristol NHS Foundation Trust, UK.
Stuart ClelandUniversity Hospitals Plymouth NHS Trust, UK.
Ana Gutierrez Del ArroyoTranslational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.
David BrealeyBloomsbury Institute of Intensive Care Medicine, University College London, London, UK.
Rupert M PearseTranslational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.
Stopping Perioperative ACE-inhibitors or angiotensin-II receptor blockers (SPACE) trial investigators
Queen Mary University of London · GBUniversity Hospitals Bristol NHS Foundation Trust · GBCounty Durham and Darlington NHS Foundation Trust · GBUniversity College London Hospitals NHS Foundation Trust · GBUniversity Hospitals Plymouth NHS Trust · GB

Funding

British Heart Foundation RG/14/4/30736
6 · The paper itself

Abstract

BACKGROUND AND

aimsHaemodynamic instability is associated with peri-operative myocardial injury, particularly in patients receiving renin-angiotensin system (RAS) inhibitors (angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers). Whether stopping RAS inhibitors to minimise hypotension, or continuing RAS inhibitors to avoid hypertension, reduces peri-operative myocardial injury remains unclear.

methodsFrom 31 July 2017 to 1 October 2021, patients aged ≥60 years undergoing elective non-cardiac surgery were randomly assigned to either discontinue or continue RAS inhibitors prescribed for existing medical conditions in six UK centres. Renin-angiotensin system inhibitors were withheld for different durations (2-3 days) before surgery, according to their pharmacokinetic profile. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury [plasma high-sensitivity troponin-T (hs-TnT) ≥ 15 ng/L within 48 h after surgery, or ≥5 ng/L increase when pre-operative hs-TnT ≥15 ng/L]. Pre-specified adverse haemodynamic events occurring within 48 h of surgery included acute hypertension (>180 mmHg) and hypotension requiring vasoactive therapy.

resultsTwo hundred and sixty-two participants were randomized to continue (n = 132) or stop (n = 130) RAS inhibitors. Myocardial injury occurred in 58 (48.3%) patients randomized to discontinue, compared with 50 (41.3%) patients who continued, RAS inhibitors [odds ratio (for continuing): 0.77; 95% confidence interval (CI) 0.45-1.31]. Hypertensive adverse events were more frequent when RAS inhibitors were stopped [16 (12.4%)], compared with 7 (5.3%) who continued RAS inhibitors [odds ratio (for continuing): 0.4; 95% CI 0.16-1.00]. Hypotension rates were similar when RAS inhibitors were stopped [12 (9.3%)] or continued [11 (8.4%)].

conclusionsDiscontinuing RAS inhibitors before non-cardiac surgery did not reduce myocardial injury, and could increase the risk of clinically significant acute hypertension. These findings require confirmation in future studies.

Indexed as

HypertensionHypotensionAngiotensin-Converting Enzyme InhibitorsAngiotensin Receptor AntagonistsAntihypertensive AgentsHumansRenin-Angiotensin SystemAngiotensin-Converting Enzyme InhibitorsAngiotensin Receptor AntagonistsAntihypertensive AgentsMajor cardiac eventsMyocardial injuryNon-cardiac surgeryPeri-operative careRenin–angiotensin system inhibitors

Identifiers

PMID37935833
PMCPMC10984566
OpenAlexW4388482793

What OpenQuestion holds

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LicenceCC BY-NC
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.