Pharmacological cardioprotection in cardiovascular anesthesia. Diltiazem vs nitroglycerin

Abstract

Introduction: in the cases of ischemic cardiopathy patients, different preventive strategies have been designed to limit the damage for ischemia-reperfusion, in order to optimize the balance in myocardial oxygen consumption. Objectives: To determine what cardio-protective (nitroglycerin or diltiazem) strategy is more effective in coronary revascularization. Methods: A randomized therapeutic trial was conducted to assess the cardio-protective effect of diltiazem and nitroglycerin in patients intervened with heart beating. Results: 175 patients were studied: the nitroglycerin group N=90 patients and the diltiazem group D=85. Sustained myocardial ischemia in group D was 20% vs. 12% in N; p=0.04. ST infra-imbalance prevailed. It was 10% in the N group vs 39% in group D; p = 0.002. The most frequent alteration was segmental hypokinesia in 36% of the patients. Akinesia was higher in group D, 9.4% vs. group N 4.4%; p = 0.05. The average value of mean intraoperative blood pressure was 80 mm/Hg in the group N vs.61.4 mm/Hg in group D; p = 0.003. The average heart rate in the group N was 63 bpm vs Group D which was 50 bpm; p = 0.006. The most common arrhythmia was atrial fibrillation 28%, in the N group 34% vs. group D 21%, p = 0.037. The average value of troponin after 24 h was 125 pg/ml in group D vs.97.7 pg/ml in group N; p = 0.042. Adverse effects were minimal. Sustained hypotension in group D was 30% vs 5.5% in group N; p = 0.002. AV block was observed in the group N 4% vs 15% in group D; p = 0.01. Perioperative IMA was 2.2 times more frequent with diltiazem than with nitroglycerin. Conclusions: Perioperative infusion of nitroglycerin provides better cardioprotective effect then diltiazem in preventing sustained ischemic events, associated with less release of T troponin and better hemodynamic stability. Diltiazem is associated with a decreased risk of postoperative atrial fibrillation. Adverse effects and complications prevailed in patients treated with diltiazem. IMA perioperative risk was 2.2 times higher in this group.