Pathogenesis and treatment for anesthesia-related coronary arterial spasm

与高加索人相比，日本人冠状动脉痉挛的发生率被认为相对较高(1)，尽管日本人冠状动脉疾病的发病率和死亡率要低得多(2)。一些围术期冠状动脉痉挛的病例报告已经发表在非索引的日本麻醉杂志上，并且在很大程度上是由日本人撰写的。个别报告显示，具有特定条件和治疗方案的患者数量相对较少，因此很难清楚地定义哪些因素会影响围手术期冠状动脉痉挛。本研究的目的是通过回顾已发表的文献，探讨影响围手术期冠状动脉痉挛的相关因素。方法：通过检索Medline(1968-1998)和日本期刊(1980-1998)，对围术期冠状动脉痉挛的报道进行检索。围术期冠状动脉痉挛的选择标准包括缺血性心电…以ST段抬高为典型表现的更多的地形学变化，在心肌需求或供应决定因素没有明显变化之前，发生率发生在全身和/或区域麻醉之前、期间或之后到达手术室后。结果：分析115例患者围手术期冠状动脉痉挛的临床特点。患者年龄36~87岁，平均岁。男性97人(84%)，女性18人(16%)。术前危险因素包括高血压(27%)、心绞痛(27%)、吸烟(13%)和糖尿病(11%)。发作与全身麻醉深度不足(23%)、血管增压剂的使用(22%)、迷走神经反射(19%)、使用血管增压剂以外的药物(17%)和硬膜外阻滞(15%)有关。除血管加压药外，其他可能的病因包括前列腺素E1、维库溴铵、多沙普兰和甲氨蝶呤。约85%的患者术前心电图无缺血性异常，而56%的患者术后冠状动脉造影显示明显的冠状动脉狭窄。吸入麻醉复合硬膜外阻滞患者易发生冠脉痉挛。硝酸盐在大多数情况下减轻了发作，而19%的患者需要除颤和心脏按摩。目前尚无死亡报告。结论：报道的围术期冠状动脉痉挛多发生在有某些术前危险因素的老年男性，如高血压、心绞痛、吸烟和糖尿病。我们的研究结果表明，引发围手术期冠状动脉痉挛的主要因素包括全身麻醉深度不足、血管增压剂的使用、迷走神经刺激以及血管增压剂以外的药物。围术期冠脉痉挛在吸入麻醉复合硬膜外麻醉下接受腹部或胸部手术的患者中很常见。自主神经系统不稳定和/或血管高反应性作为冠脉痉挛的潜在致病机制已受到广泛关注。总之，冠状动脉痉挛在有冠状动脉危险因素的老年男性患者中很常见，他们在吸入麻醉联合硬膜外麻醉下接受腹部或胸部手术。自主神经系统不稳定和/或血管高反应性可能是围术期冠状动脉痉挛的潜在发病机制。在猪冠状动脉痉挛模型中，硬膜外阻滞或吸入麻醉对5-羟色胺诱导的冠状动脉过度收缩的发生率没有影响，提示麻醉对该猪模型冠状动脉血管痉挛的影响较小。较少

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