Thoracic epidural anaesthesia in patients with unstable angina pectoris

Abstract

The effect of high thoracic epidural anaesthesia with intermittent epidural bolus injections of bupivacaine (2.5 or 5 mg ml-1) was studied in 28 patients with unstable angina pectoris. The majority of the patients had a history of previous acute myocardial infarction(s) and/or angina pectoris and severe coronary artery disease. All patients were treated with nitroglycerin infusion for greater than 24 h and were included in the study if they had chest pain, not caused by acute myocardial infarction, at bed rest or recurrent anginal pain at rest greater than 2 days after infarction. 4.4 +/- 0.3 ml of bupivacaine induced a blockade of the upper seven sympathetic segments (Th1-7) for 98 +/- 9 min. Heart rate decreased significantly from 70 +/- 3 to 64 +/- 3 beats min-1 while blood pressure was unaffected by thoracic epidural anaesthesia. In 27 patients (96%) the anaesthesia induced complete analgesia. Nitroglycerin infusion was discontinued definitely within 3 h in 26 patients (93%) and pain was thereafter controlled by means of thoracic epidural anaesthesia as the sole treatment in 23 patients (82%) and as the major treatment in 25 patients (89%). Twenty-one patients (75%) were fully mobilized and stabilized. Treatment with thoracic epidural anaesthesia lasted for 6.0 +/- 1.1 days. The number of daily epidural injections decreased significantly with time from 2.7 +/- 0.3 the first day to 0.9 +/- 0.3 the fourth day (P less than 0.01, n = 19). Two patients developed acute myocardial infarction during the anaesthesia treatment period, and one of these patients died.(ABSTRACT TRUNCATED AT 250 WORDS)

Thoracic epidural analgesia started after cardiopulmonary bypass

“…In dogs subjected to myocardial infarction, thoracic epidural analgesia has been shown to reduce myocardial infarct size by nearly 50%, to reduce myocardial oxygen consumption and to improve endocardial perfusion [10]. In patients with unstable angina, thoracic epidural analgesia has been used not only to relieve angina but also to reduce systemic and pulmonary arterial pressure without significantly affecting coronary perfusion pressure, cardiac output or stroke volume [11,12]. In vascular surgery, epidural analgesia may improve vascular graft patency by a variety of mechanisms such as increased blood flow, a reduction in platelet reactivity, increased fibrinolysis and haemodilution [13], all of which may be relevant to patients undergoing coronary grafting.…”

Thoracic epidural anaesthesia decreases the incidence of ventricular arrhythmias during acute myocardial ischaemia in the anaesthetized rat

“…Davis et al (3 1) have demonstrated that cardiac sympathetic blockade with TEA during coronary occlusion decreases myocardial infarction size in anaesthetized dogs. Furthermore, Blomberg et al (40) and Tevelenok et al (19) showed that high TEA, involving blockade of cardiac sympathetic segments, induced a fall in MAP of less than 10% in patients with unstable angina pectoris (40) and acute myocardial infarction (19). If so, the anti-arrhythmic effect of TEA may be explained by a decrease in severity of the ischaemic insult.…”

Chest Pain in Acute Myocardial Infarction

“…This might be of importance if, for example, early intervention with thoracal epidural blockade should take place [8]. The possibil ity to predict the severity of pain was further evaluated in two subsequent studies a few years ago [2,3].…”