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J Am Coll Cardiol, 2008; 51:1321-1322, doi:10.1016/j.jacc.2007.12.021
© 2008 by the American College of Cardiology Foundation
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CORRESPONDENCE: LETTER TO THE EDITOR

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Judy R. Kersten, MD, FACC* and Lee A. Fleisher, MD, FACC

* Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, Wisconsin 53226-3548 (Email: jkersten{at}mcw.edu).

There is intense interest in the actions of volatile anesthetics agents to pre- and post-condition myocardium against injury after myocardial ischemia and reperfusion. Anesthetic pre-conditioning was first demonstrated in animal models in 1997 (1,2) and in patients undergoing coronary artery bypass graft surgery in 1999 (3). The American College of Cardiology/American Heart Association 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery (4) summarize the findings of 15 randomized clinical trials in patients undergoing coronary artery bypass graft surgery demonstrating that volatile anesthetic agents decrease troponin release and enhance left ventricular function compared with several intravenous anesthetics. Studies designed to evaluate the efficacy of anesthetic pre- or post-conditioning against myocardial injury have been conducted in patients undergoing cardiac surgery because the timing and duration of the myocardial ischemic stimulus is relatively well defined. In addition, the majority of these investigations controlled for important variables that could influence anesthetic cardioprotection, such as by discontinuing sulfonylurea hypoglycemic agents that block anesthetic pre- and post-conditioning. The data indicate that volatile anesthetic agents are protective against myocardial ischemia/reperfusion injury and can likely be generalized to patients with coronary artery disease undergoing noncardiac surgery. To date, there have been no published studies specifically designed to assess the efficacy of anesthetic pre- or post-conditioning against myocardial injury in patients undergoing noncardiac surgery. Also, volatile anesthetics produce important negative inotropic effects, and the risks and benefits of these drugs in hemodynamically unstable patients are unclear. There is a great need for further investigation in this area. The conduct of adequately powered and well-controlled studies of anesthetic cardioprotection in noncardiac surgical patients will be challenging. Meta-analyses of heterogeneous clinical trials using volatile or intravenous anesthetics in patients who are at low or intermediate risk for developing myocardial ischemia due to the nature of the surgical procedure, the burden of disease, or both may not be adequate to elucidate the risks versus benefits of specific anesthetic agents to produce cardioprotection. Per the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Methodology, unpublished data cannot be used to formulate guideline recommendations. Thus, the weight of the evidence suggests that volatile anesthetics are protective against myocardial ischemia/reperfusion injury, and in the absence of data to indicate that these commonly used anesthetics increase risk in hemodynamically stable patients, their use is recommended.


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  1. Kersten JR, Schmeling TJ, Pagel PS, Gross GJ, Warltier DC. Isoflurane mimics ischemic preconditioning via activation of K(ATP) channels: reduction of myocardial infarct size with an acute memory phase Anesthesiology 1997;87:361-370.[CrossRef][ISI][Medline]
  2. Cope DK, Impastato WK, Cohen MV, Downey JM. Volatile anesthetics protect the ischemic rabbit myocardium from infarction Anesthesiology 1997;86:699-709.[ISI][Medline]
  3. Belhomme D, Peynet J, Louzy M, Launay JM, Kitakaze M, Menasche P. Evidence for preconditioning by isoflurane in coronary artery bypass graft surgery Circulation 1999;100:ii340-ii344.[Medline]
  4. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College Of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) J Am Coll Cardiol 2007;50:e159-e241.[Free Full Text]

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Cardioprotection by Volatile Anesthetics in Noncardiac Surgery? No, Not Yet At Least
Giovanni Landoni, Oliviero Fochi, and Alberto Zangrillo
J. Am. Coll. Cardiol. 2008 51: 1321. [Full Text] [PDF]




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