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A comparison of esmolol & diltiazem for heart rate control during coronary revascularisation on beating heart
1Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi.
Insights
Esmolol provided superior heart rate control during coronary artery revascularization surgery compared to diltiazem. However, esmolol increased pulmonary artery pressure, while diltiazem offered hemodynamic benefits in hypertensive patients.
Area of Science:
- Cardiology
- Cardiac Surgery
- Pharmacology
Background:
- Coronary artery revascularization without cardiopulmonary bypass requires effective hemodynamic management.
- Controlling heart rate and hemodynamics is crucial during myocardial revascularization procedures.
Purpose of the Study:
- To compare the efficacy of esmolol versus diltiazem in controlling heart rate and hemodynamics.
- To evaluate the safety and effectiveness of esmolol and diltiazem during off-pump coronary artery bypass surgery.
Main Methods:
- A prospective study involving 60 adult patients with coronary artery disease undergoing off-pump revascularization.
- Patients were randomized into two groups: one receiving esmolol, the other diltiazem, for heart rate control during anastomosis.
- Hemodynamic parameters including heart rate, systemic vascular resistance, and pulmonary pressures were monitored.
Main Results:
- Esmolol significantly improved heart rate control (51.4 bpm) compared to diltiazem (69.6 bpm).
- Esmolol led to increased mean pulmonary artery pressure and pulmonary vascular resistance.
- Diltiazem decreased systemic vascular resistance, mean pulmonary artery pressure, and pulmonary artery wedge pressure.
Conclusions:
- Esmolol offers superior heart rate reduction but necessitates caution due to potential pulmonary hypertension in patients with right ventricular dysfunction.
- Diltiazem may be a preferable option for hypertensive patients undergoing off-pump coronary artery revascularization due to its favorable hemodynamic effects.
Abstract:
This prospective study was done to compare the control of heart rate and haemodynamics during coronary artery revascularisation without cardiopulmonary bypass using either esmolol or diltiazem. Sixty adult patients with one or two vessel coronary artery disease, were randomly divided into 2 equal groups. Group A received a 500 micrograms/kg loading dose of esmolol followed by a 100 micrograms/kg/h infusion, for control of heart rate during surgical anastomosis of the coronary vessel. While Group B received 0.15 mg/kg diltiazem as a loading dose followed by a 5 mg/h infusion for heart rate control, during the anastomosis. It was seen that heart rate control was better in Group A, 51.4 (+/- 1.3) beats/min, than in Group B, 69.6 (+/- 3.9) beats/min but the decrease in heart rate was significant in both the groups at peak effect compared to respective predrug values. Group A patients had unchanged systemic resistance and pulmonary artery wedge pressure but mean pulmonary artery pressure and pulmonary vascular resistance were significantly raised. Group B patients had decreased systemic resistance, mean pulmonary artery pressure and pulmonary artery wedge pressure, and reduced right ventricular stroke work index. We concluded that although esmolol provided dramatically slower heart rates, during surgery, the resulting elevations in mean pulmonary artery pressure and pulmonary vascular resistance would require caution if used in patients with underlying right ventricular dysfunction from ischaemia or infarction. Diltiazem by virtue of its effects on systemic vascular resistance, cardiac output, and lowering of mean arterial pressure may be a better choice in hypertensive patients.