Free
Correspondence  |   November 2004
Is There Any Reason to Withhold α2Agonists from Patients with Coronary Disease during Surgery?
Author Affiliations & Notes
  • Luc Quintin, M.D., Ph.D
    *
  • * Physiology, School of Life Sciences, Lyon, France, and Columbia Hospital, West Palm Beach, Florida.
Article Information
Correspondence
Correspondence   |   November 2004
Is There Any Reason to Withhold α2Agonists from Patients with Coronary Disease during Surgery?
Anesthesiology 11 2004, Vol.101, 1244. doi:
Anesthesiology 11 2004, Vol.101, 1244. doi:
To the Editor:—
London et al.  1 and Kertai et al.  2 are to be commended for their review on β blockers and outcome. As an alternative to β blockers, after introduction of α2agonists in human anesthesia,3 several large-scale trials or meta-analyses suggested that α2agonists decrease myocardial ischemia/infarction or mortality after cardiovascular surgery.4–6 Another meta-analysis reported that β blockers decreased cardiac death from 3.9% to 0.8% and that α2agonists decreased cardiac death from 2.3% to 1.1%.7 By contrast, another point of view suggests that β blockers and α2agonists cannot carry a relative risk reduction higher than 25%.8 Authors suggested that α2agonists are an alternative when asthma/hyperreactive airway,1,2,7 atrioventricular block,1,2,7 or decompensated systolic failure7 are present. In fact, α2agonists reduce bronchoconstriction in human9 and dog10 models, and clonidine increases stroke index in patients with cardiac failure who have a New York Heart Association classification of III or IV11,12 : The sicker the patient is, the larger the systolic performance seems to increase.13,14 A recent editorial15 stated that the “53% reduction in overall mortality [due to α2agonists is] actually …more impressive that was has been found in the pooled β-blocker studies.” Given the fewer contraindications of α2agonists as compared with β blockers, we surmise that clinicians could consider α2agonists as first-line  drugs. Given the recent availability of intravenous α2agonists on the North American market, administration of α2agonists is simple: oral or intravenous or down the nasogastric tube or rectally. Appropriate reduction in anesthetic doses and volume loading in coronary/hypertensive patients presenting for major cardiovascular surgery3 or major noncardiac surgery have been delineated. As suggested,7,15 α2agonists and β blockers should be directly compared. Conversely, they may be combined to achieve maximal favorable effects.
* Physiology, School of Life Sciences, Lyon, France, and Columbia Hospital, West Palm Beach, Florida.
References
London MJ, Zaugg M, Schaub MC, Spahn DR: Perioperative β-adrenergic blockade: Physiologic foundations and clinical controversies. Anesthesiology 2004; 100:170–5London, MJ Zaugg, M Schaub, MC Spahn, DR
Kertai MD, Bax JJ, Klein J, Poldermans D: Is there any reason to withhold β blockers from high-risk patients with coronary disease during surgery? Anesthesiology 2004; 100:4–7Kertai, MD Bax, JJ Klein, J Poldermans, D
Ghignone M, Quintin L, Duke PC, Kehler CH, Calvillo O: Effects of clonidine on narcotic requirements and hemodynamic response during induction of fentanyl anesthesia and endotracheal intubation. Anesthesiology 1986; 64:36–42Ghignone, M Quintin, L Duke, PC Kehler, CH Calvillo, O
Oliver MF, Goldman L, Julian DG, Holme I: Effect of mivazerol on perioperative cardiac complications during non–cardiac surgery in patients with coronary disease. Anesthesiology 1999; 91:951–61Oliver, MF Goldman, L Julian, DG Holme, I
Nishina K, Mikawa K, Uesugi T, Obara H, Maekawa M, Kamae I, Nishi N: Efficacy of clonidine for prevention of perioperative myocardial ischemia. Anesthesiology 2002; 96:323–9Nishina, K Mikawa, K Uesugi, T Obara, H Maekawa, M Kamae, I Nishi, N
Wijeysundera DN, Naik JS, Beattie S: Alpha-2 adrenergic agonists to prevent cardiovascular complications. Am J Med 2003; 114:752Wijeysundera, DN Naik, JS Beattie, S
Stevens RD, Burri H, Tramer MR: Pharmacologic myocardial protection in patients undergoing noncardiac surgery: A quantitative systematic review. Anesth Analg 2003; 97:623–33Stevens, RD Burri, H Tramer, MR
Devereaux JP, Leslie K: Alpha-2 and beta-adrenergic antagonists reduce perioperative cardiac events. Can J Anaesth 2004; 51:291–2Devereaux, JP Leslie, K
Lindgren BR, Ekstrom T, Andersson RGG: The effects of inhaled clonidine in patients with asthma. Am Rev Resp Dis 1986; 134:266–9Lindgren, BR Ekstrom, T Andersson, RGG
Groeben H, Mitzner W, Brown RH: Effects of the α2-adrenoceptor agonist dexmedetomidine on bronchoconstriction in dogs. Anesthesiology 2004; 100:359–63Groeben, H Mitzner, W Brown, RH
Hermiller JB, Magorien RD, Leithe ME, Unverferth DV, Leier CV: Clonidine in congestive heart failure: A vasodilator with negative inotropic effects. Am J Cardiol 1983; 51:791–5Hermiller, JB Magorien, RD Leithe, ME Unverferth, DV Leier, CV
Giles TD, Iteld BJ, Mautner RK, Rognoni PA, Dillenkoffer RL: Short-term effects of intravenous clonidine in congestive heart failure. Clin Pharmacol Ther 1981; 30:724–8Giles, TD Iteld, BJ Mautner, RK Rognoni, PA Dillenkoffer, RL
Manolis AJ, Olympios C, Sifaki M, Handanis S, Bresnahan M, Gavras I, Gavras H: Suppressing sympathetic activation in congestive heart failure: A new therapeutic strategy. Hypertension 1995; 26:719–24Manolis, AJ Olympios, C Sifaki, M Handanis, S Bresnahan, M Gavras, I Gavras, H
Foresti A, Massari FM, Lotto A: Hemodynamic effects of clonidine in patients with acute myocardial infarction complicated by hypertension. J Cardiovasc Pharmacol 1986; 8(suppl 3):S30–2Foresti, A Massari, FM Lotto, A
Goldman L: Evidence-based perioperative risk reduction. Am J Med 2003; 114:763–4Goldman, L