A Recipe for Perioperative Cardioprotection

The question of what is the ideal anesthetic for patients with cardiovascular disease has been debated for nearly 3 decades, and, similar to the case for the use of perioperative β-blockers, the answer appears to be increasingly enigmatic. In the current issue of Circulation , Buse et al1 report the results of a randomized clinical trial to evaluate the effects of the volatile anesthetic sevoflurane versus the intravenous anesthetic propofol on the incidence of myocardial ischemia in 385 patients with known coronary artery disease or with ≥2 risk factors for coronary artery disease undergoing noncardiac surgery. Using continuous electrocardiography and troponin T plasma concentrations as the composite primary end point of the study, the incidence of myocardial ischemia was similar in both groups (sevoflurane, 40.8%; propofol, 40.3%), calling into question the current American College of Cardiology/American Heart Association guidelines recommending the use of volatile anesthetics for patients at cardiovascular risk who are undergoing noncardiac surgery.2Article see p 2696In the mid-1980s, volatile anesthetic agents, particularly isoflurane, were shunned by cardiac anesthesiologists for fear that these agents might induce myocardial ischemia because of coronary steal. High-dose opioids were favored as an alternative technique during anesthesia for cardiac surgery. The myth of isoflurane-induced steal was later debunked both by animal studies3 and clinical trial data.4 By the early 1990s, volatile anesthetic use during cardiac surgery had gained considerable popularity, primarily because it allowed patients to be fast-tracked for early extubation within hours of arrival to the intensive care unit as compared with opioid-based anesthetics. In 1997, the phenomenon of anesthetic preconditioning was first described,5 and subsequently a large body of experimental evidence …