Pathogenesis and treatment for anesthesia-related coronary arterial spasm

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The incidence of coronary arterial spasm is considered to be relatively high among Japanese compared to Caucasians (1), although the morbidity and mortality of coronary arterial disease are much lower in Japanese (2). A number of case reports of perioperative coronary artery spasm have been published in non-indexed Japanese anesthetic journals, and were to a large extent authored by Japanese. The individual reports show relatively small numbers of patients with specific conditions and treatment regimens, making it difficult to clearly define which factors affect perioperative coronary artery spasm. The purpose of this study is to investigate the contributing factors affecting perioperative coronary artery spasm by reviewing the published articles. Methods : Reports of the perioperative coronary artery spasm were identified by searching the Medline (1968-1998), and Japanese journals (1980-1998). The selected criteria for perioperative coronary artery spasm included ischemic electrocardi … More ographic changes as demonstrated typically by ST segment elevation without preceding remarkable changes in determinants of myocardial demand or supply, and the incidence occurred after arrival in the operating room before, during or following general and/or regional anesthesia. Results : The clinical characteristics of perioperative coronary spasm were analyzed in 115 patients. Mean age of patients was 64 years (range, 36 to 87 years). There were 97 men (84%) and 18 women (16%). Preoperative risk factors included hypertension (27%), angina pectoris (27%), cigarette smoking (13%) and diabetes mellitus (11%). The attack was related to inadequate depth of general anesthesia (23%), use of vasopressors (22%), vagal reflex (19%), administration of drugs other than vasopressors (17%) and epidural block (15%). Drugs other than vasopressors as possible causes included prostaglandin E1, vecuronuim, doxapram, and trimethaphan. About 85% of patients showed no ischemic abnormality on the preoperative electrocardiogram, while 56% had significant coronary stenosis on postoperative coronary arteriography. Coronary spasm tended to occur in patients under inhalation anesthesia combined with epidural block. Nitrates alleviated the episode in the majority of cases, while defibrillation and cardiac massage were required in 19% of patients. No death was reported. Conclusion : The reported perioperative coronary spasm occurred mostly in elderly men who had certain preoperative risk factors, such as hypertension, angina pectoris, cigarette smoking and diabetes mellitus. Our findings suggest that the major factors that trigger perioperative coronary spasm include inadequate depth of general anesthesia, the use of vasopressors, vagus nerve stimulation, and drugs other than vasopressors. Perioperative coronary spasm is prevalent in patients undergoing abdominal or thoracic surgery under inhalational anesthesia combined with epidural anesthesia. Instability of the autonomic nervous system and/or vascular hyperreactivity has received considerable attention as the underlying pathogenic mechanisms of coronary spasm. In summary, perioperative coronary spasm is prevalent in elderly male patients with coronary risk factors, who undergo abdominal or thoracic surgery under inhalational anesthesia combined with epidural anesthesia. Instability of the autonomic nervous system and/or vascular hyperreactivity may be the underlying pathogenic mechanisms of perioperative coronary spasm.In a porcine model of coronary artery spasm, the effects of epidural block or inhalational anesthesia on the incidence of serotonin-induced coronary hyperconstriction did not appeared, suggesting the minor contribution of anesthesia to coronary vasospasm in this porcine model. Less