Journal Club: CAPTAIN TRIAL: ACEI /ARB pre cardiac cath: Hold or not to hold

There is unclear evidence on holding ACEi/ ARB prior to coronary angiography reduces contrast induced nephropathy (CIN). The CAPTAIN trail just published in the American Heart Journal was a randomized trial to investigate whether holding ACEi/ ARB prior to cardiac catheterization reduces the incidence of contrast-induced AKI in patients with chronic kidney disease (CKD).

Some key points:

Total of 208 patients underwent randomization over 6 years with CKD as defined - creatinine >1.7mg/dl w/in 3 months before  cardiac catheterization and/or serum creatinine > 1.5 mg/dl w/in 1 week before cardiac catheterization

Primary outcome: incidence of AKI defined as an absolute rise in Scr of >0.5 mg/dl from baseline and/or a relative rise in Scr of > 25% compared with baseline at any time between 48 and 96 hrs post-cardiac catheterization.

Secondary outcome: absolute difference in post-procedure creatinine compared with baseline creatinine

Safety outcome was a composite of CHF or hypertension after the procedure

Results of the study demonstrate that in patients with CKD, holding compared w/ continuing ACEi/ARB prior to cardiac catheterization, with-holding ACEi/ARB resulted in a:

1.       Non-significant reduction in contrast-induced AKI

2.       Significant reduction in post-procedural rise of creatinine.

3.       Study demonstrated a strong trend toward improved clinical outcomes when ACEi/ARB was held before angiography.

4.       No adverse events were reported in the hold ACEi/ARB group

5.       Safety: no rise in CHF or HTN with holding ACEi/ARB therapy

This randomized trial does suggest that in CKD patients, it might be beneficial to hold the ACEI/ARB pre cardiac cath for some potential benefit.  A larger N would have perhaps been important to do to get a better sense of this protective effect. A multi center study would have been useful as well.