Skip to main content
SpringerLink
Log in

Kardioprotektion in der perioperativen Phase bei nichtkardialen Eingriffen

  • Chapter
Weiterbildung für Anästhesisten 2000

  • 41 Accesses

Zusammenfassung

Weltweit müssen sich Millionen von Patienten mit koronarer Herzkrankheit (KHK) oder Verdacht auf eine KHK einem nichtkardialen operativen Eingriff unterziehen. Etwa 5–15% dieser Patienten erleiden schwerwiegende kardiovaskuläre Komplikationen, die jährlich zusätzliche Gesundheitskosten in Milliardenhöhe verursachen. Eine optimale perioperative Kardioprotektion ist deshalb aus menschlicher und gesundheitspolitischer Sicht von enormer Tragweite.

Die präoperative Evaluation jedes einzelnen Patienten stellt einen wichtigen Eckpfeiler in der perioperativen Kardioprotektion dar. Sie erlaubt, Hochrisikopatienten zu erkennen und notwendige therapeutische Interventionen wie eine prophylaktische medikamentöse Kardioprotektion mit β-Blockern oder α2-Agonisten, eine Koronarangioplastie oder gar eine koronare Revaskularisation einzuleiten. Nach den Richtlinien des American College of Physicians sollte jeder Patient mit KHK oder Risikofaktoren für eine KHK — vorausgesetzt er hat kein Asthma oder relevante bradykarde Herzrhythmusstörungen — perioperativ β-blockiert werden. Diese Empfehlung basiert auf den Resultaten neuer Studien, die eine 10-fach verminderte kardiovaskuläre Komplikationsrate und ein deutlich verbessertes Langzeitüberleben nach perioperativer β-Blockade bei kardialen Risikopatienten aufzeigen konnten. Der kardioprotektive Effekt von β-Blockern und α2-Agonisten liegt im Wesentlichen in der Verhinderung stressinduzierter Tachykardien, welche insbesondere postoperativ Myokardischämien provozieren. Schließlich zählen zu den perioperativen kardioprotektiven Maßnahmen auch eine optimale Schmerztherapie, das Vermeiden von hämodynamischen Abnormitäten, eine aggressive Therapie der Hypothermie, eine optimale Volumen- und Elektrolytsubstitution, eine Hemmung der Hyperkoagulabilität und das Sistieren des perioperativen Nikotinabusus.

Die folgenden Ausführungen beziehen sich im Wesentlichen auf das perioperative Management von Patienten, die sich einem elektiven nichtkardialen operativen Eingriff unterziehen müssen.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 59.99
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 74.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Badner NH, Knill RL, Brown JE, Novick TV, Gelb AW (1999) Myocardial infarction after noncardiac surgery. Anesthesiology 88: 572–578

    Article  Google Scholar 

  2. Beattie WS, Buckley DN, Forrest JB (1993) Epidural morphine reduces the risk of postoperative myocardial ischemia in patients with cardiac risk factors. Can J Anaesth 40: 532–541

    Article  PubMed  CAS  Google Scholar 

  3. Beattie WS, Warriner CB, Etches R, Badner NH, Parsons D, Buckley N, Chan V, Girard M. (1997) The addition of continuous intravenous infusion of ketorolac to a patient-controlled analgetic morphine regime reduced postoperative myocardial ischemia in patients undergoing elective total hip or knee arthroplasty. Anesth Analg 84: 715–722

    PubMed  CAS  Google Scholar 

  4. Bennett-Guerrero E, Ayuso L, Hamilton-Davies C, White WD, Barclay GR, Smith PK, Sally AK, Muhlbaier LH, Newman MF, Mythen MG (1997) Relationship of preoperative antiendotoxin core antibodies and adverse outcome following cardiac surgery.JAMA 277: 646–650

    Article  PubMed  CAS  Google Scholar 

  5. Bode RH, Lewis KP, Zarich SW, Pierce ET, Roberts M, Kowalchuk GJ, Satwicz PR, Gibbons GW, Hunter JA, Espanol CC, Nesto RW (1996) Cardiac outcomes after peripheral vascular surgery. Anesthesiology 84: 3–13

    Article  PubMed  Google Scholar 

  6. CIBIS-II Investigators and Committees (1999) The cardiac insufficiency bisoprolol study II (CIBIS-II): a randomized trial. Lancet 353:9-13

    Google Scholar 

  7. Coriat P, Daloz M, Bousseau D, Fusciardi J, Echter E, Viars P. (1984) Prevention of intraoperative myocardial ischemia during noncardiac surgery with intravenous nitroglycerin. Anesthesiology 61: 193–196

    Article  PubMed  CAS  Google Scholar 

  8. Detsky AL, Abrams HB, McLaughlin JR, Drucker DJ, Sasson Z, Johuston N, Scott JG, Forbath N, Hilliard JR (1986) Predicting cardiac complications in patients undergoing noncardiac surgery. J Gen Inten Med 1: 211–219

    Article  CAS  Google Scholar 

  9. Dodds TM, Stone JG, Coromilas J, Weinberg M, Levy DG (1993) Prophylactic nitroglycerin infusion during noncardiac surgery does not reduce perioperative ischemia. Anesth Analg 76: 705–713

    Article  PubMed  CAS  Google Scholar 

  10. Eagle KA, Rihal CS, Mickel MC, Holmes DR, Foster ED, Gersh BJ, for the CASS Investigators and University of Michigan Heart Care Program (1997) Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. Circulation 96: 1882–1887

    PubMed  CAS  Google Scholar 

  11. Ebert TJ (1999) Is gaining control of the autonomic nervous system important to our specialty? Anesthesiology 90: 651–653

    Article  PubMed  CAS  Google Scholar 

  12. Frank SM, Higgins MS, Breslow MJ, Fleisher LA, Gorman RB, Sitzmann JV, Raff H, Beattie C. (1995) The catecholamine, Cortisol, and hemodynamic responses to mild perioperative hypothermias randomized clinical trial. Anesthesiology 82: 83–89

    Article  PubMed  CAS  Google Scholar 

  13. Garnett RL, Maclntyre A, Lindsay P, Barber GG, Cole CW, Hajjar G, McPhail NV, Ruddy TD, Stark R. (1996) Perioperative ischemia in aortic surgery: combined epidural/general anaesthesia vs general anaesthesia and iv analgesia. Can J Anaesth 43: 769–777

    Article  PubMed  CAS  Google Scholar 

  14. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O’Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE (1977) Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 297: 845–850

    Article  PubMed  CAS  Google Scholar 

  15. Gomez MN (1998) Magnesium and cardiovascular disease. Anesthesiology 89: 222–240

    Article  PubMed  CAS  Google Scholar 

  16. Gottlieb SS, McCarter RJ, Vogel RA (1998) Effect of beta-blockade on mortality among high-risk and lowrisk patients after myocardial infarction. N Engl J Med 339: 489–497

    Article  PubMed  CAS  Google Scholar 

  17. Haber HL, Simek CL, Gimple LW, Bergin JD, Subbiah K, Jayaweera AR, Powers ER, Feldman MD (1993) Why do patients with congestive heart failure tolerate the initiation of b-blocker therapy. Circulation 88: 1610–1619

    PubMed  CAS  Google Scholar 

  18. Jansen RWMM, Gurwitz JH (1994) Controversies surrounding the use of b-blockers in older patients with cardiovascular disease. Drugs Aging 4: 175–183

    Article  PubMed  CAS  Google Scholar 

  19. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KKL, Ludwig LE, Pedan A, Goldman L. (1999) Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 100: 1043–1049

    PubMed  CAS  Google Scholar 

  20. Malmberg K, Norhammar A, Wedel H, Ryen L. (1999) Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction. Long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) Study. Circulation 99: 2626–2632

    PubMed  CAS  Google Scholar 

  21. Mangano DT (1990) Perioperative cardiac morbidity. Anesthesiology 72: 153–184

    Article  PubMed  CAS  Google Scholar 

  22. Mangano DT (1997) Effects of acadesineon myocardial infarction, stroke, and death following surgery. A metaanalysis of the five international randomised trials. The Multicenter Study of Perioperative Ischemia (McSPI). JAMA 277: 325–332

    Article  PubMed  CAS  Google Scholar 

  23. Mangano DT (1998) Adverse outcomes after surgery in the year 2001-a continuing odyssey. Anesthesiology 88: 561–564

    Article  PubMed  CAS  Google Scholar 

  24. Mangano DT (1999) Assessment of the patient with cardiac disease (an anesthesiologist’s paradigm). Anesthesiology 91: 1521–1526

    Article  PubMed  CAS  Google Scholar 

  25. Mangano DT, Goldman L. (1995) Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med 333: 1750–1756

    Article  PubMed  CAS  Google Scholar 

  26. Mangano DT, Hollenberg M, Fegert G, Meyer ML London MJ, Tubau JF, Krupski WC (1991) Perioperative myocardial ischemia in patients undergoing noncardiac surgery — I: incidence and severity during the 4 day perioperative period. J Am Coll Cadiol 17: 843–850

    Article  CAS  Google Scholar 

  27. Mangano DT, Layug E, Wallace A, Tateo I, for the Multicenter Study of Perioperative Ischemia Research Group (1996) Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 335: 1713–1720

    Article  PubMed  CAS  Google Scholar 

  28. Mangano DT, Siliciano D, Hollenberg M, Leung JM, Browner WS, Goehner P, Merrick S, Verrier E., the Study of Perioperative Ischemia (SPI) Research Group (1992) Postoperative myocardial ischemia: therapeutic trials using intensive analgesia following surgery. Anesthesiology 76: 542–353

    Article  Google Scholar 

  29. Mann DL, Kent RL, Parsons B, Cooper G. (1992) Adrenergic effects on the biology of adult mammalian cardiocytes. Circulation 85: 790–804

    PubMed  CAS  Google Scholar 

  30. McSPI-EUROPE Research Group (1997) Perioperative sympatholysis: beneficial effects of the a2-adrenoceptor agonist mivazerol on hemodynamic stability and myocardial ischemia. Anesthesiology 86:346-363

    Google Scholar 

  31. Nabel EG, Selwyn AP, Ganz P. (1990) Paradoxical narrowing of atherosclerotic coronary arteries induced by increases in heart rate. Circulation 81: 850–859

    Article  PubMed  CAS  Google Scholar 

  32. Oliver MF, Goldman L, Julian DG, Holme I, for the Mivazerol Trial Investigators Research Group The European Mivazerol Trial (EMIT) (1999) Effect of mivazerol on perioperative cardiac complications during noncardiac surgery in patients with coronary heart disease. Anesthesiology 91: 951–961

    Article  PubMed  CAS  Google Scholar 

  33. Poldermans D, Boersma E, Bax JJ, Thomson IR, Van de Ven LLM, Blankensteijn JD, Baars HF, Yo T-I, Trocino G, Vigna C, Roelandt JRTC, Van Urk H, for the Dutch Echocardiography cardiac Risk Evaluation applying Stress Echocardiography Study Group (1999) The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med 341: 1789–1794

    Article  PubMed  CAS  Google Scholar 

  34. Posner KL, Van Norman GA, Chan V. (1999) Adverse cardiac outcomes after noncardiac surgery in patients with prior percutaneous transluminal coronary angioplasty. Anesth Analg 89: 553–560

    PubMed  CAS  Google Scholar 

  35. Raby KE, Brull SJ, Timimi F, Akhtar S, Rosenbaum S, Naimi C, Whittemore AD (1999) The effect of heart rate control on myocardial ischemia among high-risk patients after vascular surgery. Anesth Analg 88: 477–482

    PubMed  CAS  Google Scholar 

  36. Reich DL, Bodian CA, Krol M, Kuroda M, Osinski T, Thys DM (1999) Intraoperative hemodynamic predictors of mortality, stroke, and myocardial infarction after coronary artery bypass surgery. Anesth Analg 89: 814–822

    PubMed  CAS  Google Scholar 

  37. Roizen MF (1988) Sould we all have a sympathectomy at birth? Or at least preoperatively? Anesthesiology 68: 482–484

    Article  PubMed  CAS  Google Scholar 

  38. Shah AS, Lilly RE, Kypson AP, Tai O, Hata JA, Pippen A, Silvestry SC, Lefkowitz RJ, Glower DD, Koch WJ (2000) Intracoronary adenovirus-mediated delivery and overexpression of b2-adrenergic receptor in the heart. Circulation 101: 408–414

    PubMed  CAS  Google Scholar 

  39. Soumerai SB, McLaughlin TJ, Spiegelman D, Hertzmark E, Thibault G, Goldman L. (1997) Adverse outcomes of underuse of b-blockers in elderly survivors of acute myocardial infarction. JAMA 277: 115–121

    Article  PubMed  CAS  Google Scholar 

  40. Spahn DR, Leone BJ, Reves JG, Pasch T. (1994) Cardiovascular and coronary physiology of acute isovolemic hemodilution: a review of nonoxygen-carrying and oxygen-carrying solutions. Anesth Analg 78: 1000–1021

    Article  PubMed  CAS  Google Scholar 

  41. Stangeland L, Grong K, Vik-Mo H, Andersen K, Lekven J. (1986) Is reduced cardiac performance the only mechanism for myocardial infarct size reduction during beta-adrenergic blockade? Cardiovasc Res 20: 322–330

    Article  PubMed  CAS  Google Scholar 

  42. Stone G, Foêx P, Sear JW, Johnson LL, Khambatta HJ, Triner L. (1988) Myocardial ischemia in untreated hypertensive patients: effect of a single small oral dose of a beta-adrenergic blocking agent. Anesthesiology 68: 495–500

    Article  PubMed  CAS  Google Scholar 

  43. Stuhmeier K-D, Mainzer B, Cierpka J, Sandmann W, Tarnow J. (1996) Small, oral dose of clonidine reduces the incidence of intraoperative myocardial ischemia in patients having vascular surgery. Anesthesiology 85: 706–712

    Article  PubMed  CAS  Google Scholar 

  44. The American College of Physicians (1997) Clinical Guideline, Part I: guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major noncardiac surgery. Ann Intern Med 127: 309-312

    Google Scholar 

  45. Tomai F, Crea F, Chiariello L, Gioffrè PA (1999) Ischemic preconditioning in humans, models, mediators, and clinical relevance. Circulation 100: 559–563

    PubMed  CAS  Google Scholar 

  46. Wallace A, Layug B, Tateo I, Hollenberg M, Browner W, Miller D, Mangano DT, for the McSPI Research Group (1998) Prophylactic atenolol reduces postoperative myocardial ischemia. Anesthesiology 88: 7–17

    Article  PubMed  CAS  Google Scholar 

  47. Warltier DC (1998) b-Adrenergic-blocking drugs: incredibly useful, incredibly underutilized. Anesthesiology 88: 2–5

    Article  PubMed  CAS  Google Scholar 

  48. Yeager MP, Glass DD, Neff RK, Brinck-Johnsen TB (1987) Epidural anesthesia and analgesia in high-risk patients. Anesthesiology 66: 729–736

    Article  PubMed  CAS  Google Scholar 

  49. Zaugg M, Tagliente T, Lucchinetti E, Jacobs E, Krol M, Bodian C, Reich DL, Silverstein JH (1999) Beneficial effects from b-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology 91: 1674–1686

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Institut für Anästhesiologie, UniversitätsSpital Zürich, Rämistrasse 100, CH-8091, Zürich, Switzerland

    Dr. M. Zaugg

Authors
  1. Dr. M. Zaugg
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Klinik für Anästhesiologie, Universität Heidelberg, Im Neuenheimer Feld 110, D-69120, Heidelberg, Germany

    Hubert J. Bardenheuer

  2. Klinik für Anästhesiologie und operative Intensivmedizin, Zentralklinikum, Stenglinstraße 2, D-86156, Augsburg, Germany

    Helmuth Forst

  3. Klinik für Anästhesiologie, Medizinische Einrichtungen der RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany

    Rolf Rossaint

  4. Service d’Anesthésiologie Centre Hospitalier, Universitaire Vaudois — CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland

    Donat R. Spahn

Rights and permissions

Reprints and permissions

Copyright information

© 2001 Springer-Verlag Berlin Heidelberg

About this chapter

Cite this chapter

Zaugg, M. (2001). Kardioprotektion in der perioperativen Phase bei nichtkardialen Eingriffen. In: Bardenheuer, H.J., Forst, H., Rossaint, R., Spahn, D.R. (eds) Weiterbildung für Anästhesisten 2000. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-56596-0_11

Download citation

  • DOI: https://doi.org/10.1007/978-3-642-56596-0_11

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-540-41277-9

  • Online ISBN: 978-3-642-56596-0

  • eBook Packages: Springer Book Archive

Publish with us

Policies and ethics

Search

Navigation