Randomized Comparison of Sevoflurane Versus Propofol to Reduce Perioperative Myocardial Ischemia in Patients Undergoing Noncardiac Surgery

Abstract

Background-Volatile anesthetics provide myocardial preconditioning in coronary surgery patients. We hypothesized that sevoflurane compared with propofol reduces the incidence of myocardial ischemia in patients undergoing major noncardiac surgery. Methods and Results-We enrolled 385 patients at cardiovascular risk in 3 centers. Patients were randomized to maintenance of anesthesia with sevoflurane or propofol. We recorded continuous ECG for 48 hours perioperatively, measured troponin T and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) on postoperative days 1 and 2, and evaluated postoperative delirium by the Confusion Assessment Method. At 6 and 12 months, we contacted patients by telephone to assess major adverse cardiac events. The primary end point was a composite of myocardial ischemia detected by continuous ECG and/or troponin elevation. Additional end points were postoperative NT-proBNP concentrations, major adverse cardiac events, and delirium. Patients and outcome assessors were blinded. We tested dichotomous end points by 2 test and NT-proBNP by Mann-Whitney test on an intention-to-treat basis. Myocardial ischemia occurred in 75 patients (40.8%) in the sevoflurane and 81 (40.3%) in the propofol group (relative risk, 1.01; 95% confidence interval, 0.78 -1.30). NT-proBNP release did not differ across allocation on postoperative day 1 or 2. Within 12 months, 14 patients (7.6%) suffered a major adverse cardiac event after sevoflurane and 17 (8.5%) after propofol (relative risk, 0.90; 95% confidence interval, 0.44 -1.83). The incidence of delirium did not differ (11.4% versus 14.4%; Pϭ0.379). Conclusions-Compared with propofol, sevoflurane did not reduce the incidence of myocardial ischemia in high-risk patients undergoing major noncardiac surgery. The sevoflurane and propofol groups did not differ in postoperative NT-proBNP release, major adverse cardiac events at 1 year, or delirium. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00286585.

Perioperative cardiovascular complications versus perioperative bleeding in consecutive patients with known cardiac disease undergoing non-cardiac surgery. Focus on antithrombotic medication. The PRAGUE-14 registry

“…However, major adverse cardiac events occurred in only 8 % [11]. A large study in patients with atherosclerosis or at risk for it undergoing non-cardiac surgery found myocardial infarction in 5 % and troponin release in 8 % of patients [12].…”

Impact of catecholamines in cardiac arrest due to acute asphyxia—a study in piglets

“…The effect of lower pretest endtidal sevoflurane concentrations in nonsurvivors—despite of higher epinephrine and norepinephrine plasma concentrations—remains unclear. It could be hypothesized that they were ‘weaker’ animals or had reduced organ protection by sevoflurane, whereas the latter is controversially debated in the literature . On the other side, it is unclear why ‘weaker’ animals should have longer times from apnea until circulatory arrest.…”

Postoperative Delirium: A Review of Risk Factors and Tools of Prediction

“…Another area of interest is whether particular medications are more likely to cause postoperative delirium. A recent RCT comparing maintenance of anesthesia with sevoflurane or propofol found no difference in the incidence of delirium between the two groups [79]. Radtke and coauthors found the intraoperative use of fentanyl, as opposed to remifentanil, to be an independent predictive factor for POD [31].…”