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Perioperative medikamentöse Kardioprotektion

Systematische Literaturübersicht als rationale Grundlage zur Prozessoptimierung

Perioperative pharmacological myocardial protection

Systematic literature-based process optimization

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Zusammenfassung

Schwere perioperative Komplikationen bei kardialen Hochrisikopatienten sind häufig und mit einer hohen Letalität verbunden. Die Studienlage für eine perioperative β-Blocker-Therapie ist heterogen, und teilweise divergierende Ergebnisse machen eine umsichtige Interpretation erforderlich, insbesondere wenn hieraus globale therapeutische Empfehlungen für viele Millionen Patienten abgeleitet werden. Für eine perioperative β-Blocker-Therapie besteht nur bei einer limitierten Subpopulation kardialer Hochrisikopatienten – insbesondere bei gefäßchirurgischen Eingriffen – eine ausreichende Evidenz. Perioperative β-Blocker sind bei Patienten mit moderatem Risiko neutral und bei Patienten mit niedrigem Risiko sogar potenziell schädlich. Der Schlüssel für eine rationale Therapie ist daher eine individuelle differenzierte Nutzen-Risiko-Bewertung. Diese erfolgt als standardisiertes protokollbasiertes kardiales Screening; ein hierfür entworfener Evaluationsbogen wird vorgestellt. Als zentrales Scoresystem kann der Revised Cardiac Risk Index nach Lee (RCRI) empfohlen werden. Eine aktuelle Studie (POISE) demonstriert, dass eine relativ hoch dosierte orale perioperative Metoprololtherapie die Inzidenz kardiovaskulärer Ereignisse effektiv senkt. Jedoch wird die Gesamtletalität aufgrund erheblicher Nebenwirkungen (Hypotension, Bradykardie, Schlaganfall) erhöht. Ein besonderes Augenmerk ist daher auf die Dosisanpassung und die Sicherheitsaspekte einer β-Blocker-Therapie sowie auf das flankierende Monitoring zu richten. Clonidin ist ein Alternativpräparat bei Patienten mit zusätzlichen pulmonalen Risikofaktoren. Bestehende Studien geben keinen Anhalt dafür, wie eine medikamentöse Kardioprotektion in den perioperativen Prozess implementiert werden kann. Dieser Artikel stellt hierfür ein einfaches klinisches Konzept vor.

Abstract

Patients with major cardiac risk factors have been suggested to benefit from perioperative β-blockade. However, the scientific literature on perioperative β-blockade needs to be interpreted carefully. So far treatment recommendations for millions of patients are based on heterogeneous data from randomized trials with divergent study results. The evidence for a beneficial effect of perioperative β-blockers is sufficient only for a limited subpopulation of high cardiac risk patients undergoing vascular surgery. Perioperative β-blocker treatment is not useful in patients with intermediate risk and may even be harmful in patients with low cardiac risk. Therefore, an individualized risk-benefit analysis is an important prerequisite for a rational therapy that may be based on a standardized protocol including the Revised Cardiac Risk Index. Such a protocol is presented in this article. A recently reported trial (POISE) demonstrated that perioperative treatment with high doses of oral metoprolol efficiently reduces the incidence of cardiovascular events. However, due to severe adverse effects (hypotension, bradycardia, stroke) the total mortality was increased. Thus, dose adjustments, safety aspects, and monitoring of β-blocker therapy seem to be mandatory. So far evidence from relevant trials about how to best implement perioperative β-blockade is lacking. This article offers a simple clinical concept for this purpose.

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  1. Zentrum für Anästhesiologie und Intensivmedizin, Universitätskrankenhaus Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland

    M. Petzoldt, A.E. Goetz & P. Friederich

  2. Klinik und Poliklinik für Kardiologie/Angiologie, Universitäres Herzzentrum Hamburg, Hamburg, Deutschland

    J. Kähler

  3. Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Klinikum Bogenhausen, München, Deutschland

    P. Friederich

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  1. M. Petzoldt
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Petzoldt, M., Kähler, J., Goetz, A. et al. Perioperative medikamentöse Kardioprotektion. Anaesthesist 57, 655–669 (2008). https://doi.org/10.1007/s00101-008-1396-9

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