New therapy in cardioprotection

An increasing number of patients are presenting for major surgery with cardiovascular comorbidities. Evidence of myocardial injury was found in 8% of all noncardiac surgery patients older than 45 years and was associated with adverse outcome. For this reason, there has been a lot of interest in finding and evaluating effective cardioprotective interventions.

Current evidence suggests that statins, volatile anesthetic agents, and propofol are cardioprotective. Beta blockers reduce myocardial injury, but the resultant hypotension may contribute to the increased all-cause mortality and stroke risk seen. Likewise, alpha 2 agonists can be a cause of cardiac injury if hypotension is not promptly managed. Continuation of aspirin perioperatively can increase the risk of major bleeding with or without the benefit of reduced myocardial risk. Contrary to the initial Evaluation of Nitrous Oxide in the Gas Mixture for Anaesthesia study, nitrous oxide does not seem to increase the risk of myocardial injury.

It is recommended that patients already on statins or beta blockers should have them continued perioperatively. If beta blockers are initiated, the dose should be titrated to heart rate and blood pressure. The decision regarding continuation of aspirin should be on a case-to-case basis based on patient and surgical risk factors.