Epidural Morphine Reduces the Risk of Postoperative Myocardial Ischaemia in Patients with Cardiac Risk Factors

Overview

Journal Can J Anaesth

Specialty Anesthesiology

Date 1993 Jun 1

PMID 8403120

Citations 21

Authors

W S Beattie

D N Buckley

J B Forrest

Affiliations

Soon will be listed here.

Abstract

Perioperative myocardial ischaemia is a predictor of postoperative cardiac morbidity (PCM). Epidural anaesthesia and adequate perioperative analgesia have been shown to improve myocardial oxygen dynamics due to interruption of pain and sympathetic pathways. The aim of the present study was to compare the incidence of ischaemia after either general anaesthesia followed by parenteral analgesia with morphine or combined epidural/general anaesthesia followed by analgesia with epidural morphine. In a prospective observer-blinded analysis of the occurrence of ischaemia, 55 patients (epidural = 29/parenteral = 26) scheduled for elective surgery with defined risks for ischaemic cardiac disease were entered and followed for 24 hr after surgery with two-lead continuous Holter monitoring. Groups were similar with respect to age, weight, modified Goldman (Detsky) risk classification and the use of cardiac medications. Fewer patients receiving the epidural anaesthesia/analgesia had ischaemic episodes (17.2 vs 50.0%, P = 0.01), and tachyarrhythmias (20.7 vs 50.0%, P < 0.05). Epidural patients had a four-fold reduction of the relative risk for either event (P < 0.001). All ischaemic events were asymptomatic and unrecognized (silent). All major morbid events (n = 5) (MI, congestive heart failure and death) occurred in patients who had perioperative episodes of ischaemia. There were three distinct peaks in onset of ischaemia, at 1-4 hr, 9-12 hr and 22-24 hr postoperatively. One third of postoperative ischaemic events occurred within the first four hours after operation and lasted from 1 to 31 min. Forty-two percent of ischaemic episodes were associated with a heart rate > 100 bpm, or an increase of 20% over the baseline heart rate. We conclude that epidural anaesthesia/analgesia reduces but does not eliminate the risk of myocardial ischaemia and tachyarrhythmia. We were unable to determine any associated reduction in the risk of PCM.

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References

Fujita M, Franklin D . Diurnal changes in coronary blood flow in conscious dogs. Circulation. 1987; 76(2):488-91. DOI: 10.1161/01.cir.76.2.488. View

Rocco M, Barry J, Campbell S, Nabel E, Cook E, Goldman L . Circadian variation of transient myocardial ischemia in patients with coronary artery disease. Circulation. 1987; 75(2):395-400. DOI: 10.1161/01.cir.75.2.395. View

Detsky A, Abrams H, McLaughlin J, Drucker D, Sasson Z, Johnston N . Predicting cardiac complications in patients undergoing non-cardiac surgery. J Gen Intern Med. 1986; 1(4):211-9. DOI: 10.1007/BF02596184. View

Slogoff S, KEATS A . Does perioperative myocardial ischemia lead to postoperative myocardial infarction?. Anesthesiology. 1985; 62(2):107-14. DOI: 10.1097/00000542-198502000-00002. View

Vedrinne C, Vedrinne J, Guiraud M, Patricot M, Bouletreau P . Nitrogen-sparing effect of epidural administration of local anesthetics in colon surgery. Anesth Analg. 1989; 69(3):354-9. View

Blomberg S, Emanuelsson H, Ricksten S . Thoracic epidural anesthesia and central hemodynamics in patients with unstable angina pectoris. Anesth Analg. 1989; 69(5):558-62. View

KNIGHT A, Hollenberg M, London M, Tubau J, Verrier E, Browner W . Perioperative myocardial ischemia: importance of the preoperative ischemic pattern. Anesthesiology. 1988; 68(5):681-8. View

Mulcahy D, Keegan J, Cunningham D, Quyyumi A, Crean P, Park A . Circadian variation of total ischaemic burden and its alteration with anti-anginal agents. Lancet. 1988; 2(8614):755-9. DOI: 10.1016/s0140-6736(88)92414-2. View

Boucher C, Brewster D, DARLING R, Okada R, Strauss H, Pohost G . Determination of cardiac risk by dipyridamole-thallium imaging before peripheral vascular surgery. N Engl J Med. 1985; 312(7):389-94. DOI: 10.1056/NEJM198502143120701. View

10.

Willich S, Bhatia S, Shook T, Tofler G, Muller J, Curtis D . Suppression of silent ischemia by metoprolol without alteration of morning increase of platelet aggregability in patients with stable coronary artery disease. Circulation. 1989; 79(3):557-65. DOI: 10.1161/01.cir.79.3.557. View

11.

CUTLER B, Leppo J . Dipyridamole thallium 201 scintigraphy to detect coronary artery disease before abdominal aortic surgery. J Vasc Surg. 1987; 5(1):91-100. DOI: 10.1067/mva.1987.avs0050091. View

12.

Raby K, Goldman L, Creager M, Cook E, Weisberg M, Whittemore A . Correlation between preoperative ischemia and major cardiac events after peripheral vascular surgery. N Engl J Med. 1989; 321(19):1296-300. DOI: 10.1056/NEJM198911093211904. View

13.

. Reduction of infarct size with the early use of timolol in acute myocardial infarction. N Engl J Med. 1984; 310(1):9-15. DOI: 10.1056/NEJM198401053100103. View

14.

Deanfield J, Ribiero P, Oakley K, Krikler S, Selwyn A . Analysis of ST-segment changes in normal subjects: implications for ambulatory monitoring in angina pectoris. Am J Cardiol. 1984; 54(10):1321-5. DOI: 10.1016/s0002-9149(84)80090-9. View

15.

Breslow M, JORDAN D, Christopherson R, Rosenfeld B, MILLER C, Hanley D . Epidural morphine decreases postoperative hypertension by attenuating sympathetic nervous system hyperactivity. JAMA. 1989; 261(24):3577-81. View

16.

Deanfield J, Shea M, Selwyn A . Clinical evaluation of transient myocardial ischemia during daily life. Am J Med. 1985; 79(3A):18-24. DOI: 10.1016/0002-9343(85)90489-9. View

17.

Rosing D, BRAKMAN P, REDWOOD D, Goldstein R, Beiser G, ASTRUP T . Blood fibrinolytic activity in man. Diurnal variation and the response to varying intensities of exercise. Circ Res. 1970; 27(2):171-84. DOI: 10.1161/01.res.27.2.171. View

18.

Berglund U, Lassvik C, Wallentin L . Effects of the platelet inhibitor ticlopidine on exercise tolerance in stable angina pectoris. Eur Heart J. 1987; 8(1):25-30. DOI: 10.1093/oxfordjournals.eurheartj.a062155. View

19.

Brezinski D, Tofler G, Muller J, Willich S, Schafer A, Czeisler C . Morning increase in platelet aggregability. Association with assumption of the upright posture. Circulation. 1988; 78(1):35-40. DOI: 10.1161/01.cir.78.1.35. View

20.

von Arnim T, Hofling B, Schreiber M . Characteristics of episodes of ST elevation or ST depression during ambulatory monitoring in patients subsequently undergoing coronary angiography. Br Heart J. 1985; 54(5):484-8. PMC: 481934. DOI: 10.1136/hrt.54.5.484. View