The role of Volatile Anesthetics in Cardioprotection: a systematic review

Abstract

This review evaluates the mechanism of volatile anesthetics as cardioprotective agents in both clinical and laboratory research and furthermore assesses possible cardiac side effects upon usage. Cardiac as well as non-cardiac surgery may evoke perioperative adverse events including: ischemia, diverse arrhythmias and reperfusion injury. As volatile anesthetics have cardiovascular effects that can lead to hypotension, clinicians may choose to administer alternative anesthetics to patients with coronary artery disease, particularly if the patient has severe preoperative ischemia or cardiovascular instability. Increasing preclinical evidence demonstrated that administration of inhaled anesthetics - before and during surgery - reduces the degree of ischemia and reperfusion injury to the heart. Recently, this preclinical data has been implemented clinically, and beneficial effects have been found in some studies of patients undergoing coronary artery bypass graft surgery. Administration of volatile anesthetic gases was protective for patients undergoing cardiac surgery through manipulation of the potassium ATP (KATP) channel, mitochondrial permeability transition pore (mPTP), reactive oxygen species (ROS) production, as well as through cytoprotective Akt and extracellular-signal kinases (ERK) pathways. However, as not all studies have demonstrated improved outcomes, the risks for undesirable hemodynamic effects must be weighed against the possible benefits of using volatile anesthetics as a means to provide cardiac protection in patients with coronary artery disease who are undergoing surgery.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

“…Rationale: Isoflurane, a volatile anesthetic, is traditionally used for general anesthesia. It has a relatively rapid onset and recovery and has demonstrated cardioprotective effects such as preserved mitochondrial oxygen consumption, troponin release, and myocardial infarction (122). Little is known of the analgesic effects of isoflurane for periprocedural pain in ICU patients.…”

Mitochondrial Potassium Channels as Pharmacological Target for Cardioprotective Drugs

“…Zaugg et al verified that exposing cardiomyocytes to the volatile anesthetics, sevoflurane and isoflurane, before myocardial ischemia, reduced the damage in a dose‐dependent manner . These effects were antagonized by the mitoK ATP channel blocker 5‐HD, demonstrating that they prime the mitoK ATP channels …”

Anaesthetics as cardioprotectants: translatability and mechanism

“…MAPKs may act as triggers and mediators in ischaemic preconditioning, while they do not trigger, but may have mediator effects in anaesthetic preconditioning (da Silva et al ., ). There are several excellent older and more recent articles that review various aspects related to the mechanisms of anaesthetic‐induced cardioprotection, particularly in respect of the relevant signalling pathways (Zaugg et al ., ; De Hert et al ., ; Pagel, ; Weber and Schlack, ; Pagel and Hudetz, ; Van Allen et al ., ; Alvarez et al ., ). Up to now, how and where small pharmacologic agents such as the practically inert volatile anaesthetics or noble gases exert their direct action that lead to protection against ischaemia and reperfusion injury remains largely unresolved.…”