Efficacy of prophylactic doses of intravenous nitroglycerin in preventing myocardial ischemia under general anesthesia: A systematic review and meta-analysis with trial sequential analysis

Hoshijima, Hiroshi; Denawa, Yohei; Mihara, Takahiro; Takeuchi, Risa; Kuratani, Norifumi; Mieda, Tsutomu; Iwase, Yoshinori; Shiga, Toshiya; Wajima, Zen’ichiro; Nagasaka, Hiroshi

doi:10.1016/j.jclinane.2017.03.040

Cited by 5 publications

(5 citation statements)

References 31 publications

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Section: Discussionmentioning

confidence: 99%

“…Even though the cardioprotective effects of nitrates are well-established [ 3 ], whether nitrates are cardioprotective in patients undergoing CABG ± valve surgery is not clear with mixed results from clinical studies [ 6 ] and meta-analyses [ 18 ], although prospective randomised controlled trials have been limited. Prior evidence that suggest a possible protective effect of GTN include a 2017 meta-analysis of secondary data from five small trials (total 180 patients) in patients undergoing cardiac surgery which showed a trend towards less PMI but it did not reach statistical significance [ 18 ]. A post-hoc retrospective analysis in CABG ± valve patients found that patients administered intraoperative IV GTN for clinical indications, administered after induction of anaesthesia and stopped when patient went onto cardiopulmonary bypass, had 39% less PMI (assessed by 72 h-AUC-hs-cTnT), when compared to control [ 6 ].…”

Section: Discussionmentioning

confidence: 99%

“…Prophylactic intraoperative intravenous (IV) GTN is administered in some patients during cardiac surgery to control systemic blood pressure, and to vasodilate arterial grafts. There is extensive experimental data supporting the cardioprotective effects of NO [ 3 , 10 , 14 , 40 ], but whether it is cardioprotective during cardiac surgery remains unclear [ 6 , 18 , 22 ]. Randomised controlled trials evaluating the cardioprotective effects of intraoperative IV GTN in patients undergoing cardiac bypass surgery are limited [ 18 ], and there are no prospective studies evaluating the interaction between nitrate use and RIPC in terms of cardioprotection in patients undergoing cardiac surgery.…”

Section: Introductionmentioning

confidence: 99%

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Negative interaction between nitrates and remote ischemic preconditioning in patients undergoing cardiac surgery: the ERIC-GTN and ERICCA studies

Hamarneh

Bulluck

et al. 2022

Basic Res Cardiol

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Remote ischaemic preconditioning (RIPC) using transient limb ischaemia failed to improve clinical outcomes following cardiac surgery and the reasons for this remain unclear. In the ERIC-GTN study, we evaluated whether concomitant nitrate therapy abrogated RIPC cardioprotection. We also undertook a post-hoc analysis of the ERICCA study, to investigate a potential negative interaction between RIPC and nitrates on clinical outcomes following cardiac surgery. In ERIC-GTN, 185 patients undergoing cardiac surgery were randomized to: (1) Control (no RIPC or nitrates); (2) RIPC alone; (3); Nitrates alone; and (4) RIPC + Nitrates. An intravenous infusion of nitrates (glyceryl trinitrate 1 mg/mL solution) was commenced on arrival at the operating theatre at a rate of 2–5 mL/h to maintain a mean arterial pressure between 60 and 70 mmHg and was stopped when the patient was taken off cardiopulmonary bypass. The primary endpoint was peri-operative myocardial injury (PMI) quantified by a 48-h area-under-the-curve high-sensitivity Troponin-T (48 h-AUC-hs-cTnT). In ERICCA, we analysed data for 1502 patients undergoing cardiac surgery to investigate for a potential negative interaction between RIPC and nitrates on clinical outcomes at 12-months. In ERIC-GTN, RIPC alone reduced 48 h-AUC-hs-cTnT by 37.1%, when compared to control (ratio of AUC 0.629 [95% CI 0.413–0.957], p = 0.031), and this cardioprotective effect was abrogated in the presence of nitrates. Treatment with nitrates alone did not reduce 48 h-AUC-hs-cTnT, when compared to control. In ERICCA there was a negative interaction between nitrate use and RIPC for all-cause and cardiovascular mortality at 12-months, and for risk of peri-operative myocardial infarction. RIPC alone reduced the risk of peri-operative myocardial infarction, compared to control, but no significant effect of RIPC was demonstrated for the other outcomes. When RIPC and nitrates were used together they had an adverse impact in patients undergoing cardiac surgery with the presence of nitrates abrogating RIPC-induced cardioprotection and increasing the risk of mortality at 12-months post-cardiac surgery in patients receiving RIPC.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Negative interaction between nitrates and remote ischemic preconditioning in patients undergoing cardiac surgery: the ERIC-GTN and ERICCA studies

Hamarneh

Bulluck

et al. 2022

Basic Res Cardiol

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“…Control group has not been used as there has been previous literature proving that nitroglycerine has effects on the HR and blood pressure and is being used in hospitalised patients with angina, hypertension and heart failure in areas other than anaesthesia. [ 9 10 ] The doses used in our study have been used in previous studies as nasal spray effectively to attenuate haemodynamic changes to laryngoscopy and intubation. [ 5 6 11 ]…”

Section: Discussionmentioning

confidence: 99%

Assessment of the effect of two different doses of intranasal nitroglycerine spray on attenuation of haemodynamic stress response to pneumoperitoneum in laparoscopic surgeries: A randomised, double-blinded study

Nagaraja¹,

Nethra²,

Rajendran³

et al. 2022

Indian Journal of Anaesthesia

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Background and Aims: The stress response to pneumoperitoneum can be deleterious due to its effects on haemodynamics, thereby increasing the morbidity. We intended to compare different doses of nitroglycerine nasal spray to obtund these responses and to look for any side effects. Methods: After ethical committee clearance and clinical trials registration, 70 patients scheduled for laparoscopic cholecystectomy were recruited. Random allocation was done into two groups by a computer generated randomisation table. Group N4 (n = 35) received 400 μg nitroglycerine and group N8 (n = 35) received 800 μg nitroglycerine with an intranasal spray 2 min prior to pneumoperitoneum. All the haemodynamic parameters were monitored at regular intervals. Results: The heart rate was comparable between the groups except at 6 and 10 min of pneumoperitoneum but showed significant increase from baseline within the groups. Mean arterial pressure (MAP) was statistically significant between the groups, being higher in group N4. Within group N4, MAP was significantly low only at 2 min, 4 min of pneumoperitoneum (101.69 ± 12.34 at baseline versus 93.31 ± 8.07 at 2 min and 97.54 ± 9.07 mm Hg at 4 min) and increased significantly at 30 min of pneumoperitoneum (101.69 ± 12.34 at baseline versus 105.66 ± 12.35 mm Hg) and hence, MAP was observed to be around baseline throughout the rest of intraoperative period. Within group N8, there was a significant decrease in mean, systolic and diastolic blood pressure from baseline at most of the time intervals. Conclusion: 800 μg of intranasal nitroglycerine effectively obtunds the hypertensive response associated with pneumoperitoneum as compared to 400 μg without significant side effects.

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“…Previous studies have investigated other agents as an alternative to magnesium sulfate [11,12]. A prospective nonrandomized cohort study examining the tocolytic effect of atosiban after open fetal myelomeningocele repair demonstrated similar short-term uterine outcome without serious maternal complications as compared to magnesium sulfate [13].…”

Section: Discussionmentioning

confidence: 99%

Successful Anesthesia Management of Postoperative Maternal Pulmonary Edema and Uterine Hyperactivity following Open Fetal Myelomeningocele Repair

Snegovskikh

Svokos

Souza

et al. 2021

Case Reports in Anesthesiology

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Effective tocolysis is essential after fetal myelomeningocele repair and is associated with the development of pulmonary edema. The increased uterine activity in the immediate postoperative period is commonly treated with magnesium sulfate. However, other tocolytic agents such as nitroglycerine, nifedipine, indomethacin, terbutaline, and atosiban (outside the US) have also been used to combat uterine contractility. The ideal tocolytic regimen which balances the risks and benefits of in-utero surgery has yet to be determined. In this case report, we describe a unique case of fetal myelomeningocele repair complicated by maternal pulmonary edema and increased uterine activity resistant to magnesium sulfate therapy.

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Efficacy of prophylactic doses of intravenous nitroglycerin in preventing myocardial ischemia under general anesthesia: A systematic review and meta-analysis with trial sequential analysis

Cited by 5 publications

References 31 publications

Negative interaction between nitrates and remote ischemic preconditioning in patients undergoing cardiac surgery: the ERIC-GTN and ERICCA studies

Negative interaction between nitrates and remote ischemic preconditioning in patients undergoing cardiac surgery: the ERIC-GTN and ERICCA studies

Assessment of the effect of two different doses of intranasal nitroglycerine spray on attenuation of haemodynamic stress response to pneumoperitoneum in laparoscopic surgeries: A randomised, double-blinded study

Successful Anesthesia Management of Postoperative Maternal Pulmonary Edema and Uterine Hyperactivity following Open Fetal Myelomeningocele Repair

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