Alpha-2 adrenergic agonists to prevent perioperative cardiovascular complications:: A meta-analysis

doi:10.1016/S0002-9343(03)00165-7

The American Journal of Medicine

Volume 114, Issue 9, 15 June 2003, Pages 742-752

https://doi.org/10.1016/S0002-9343(03)00165-7 Get rights and content

Abstract

Purpose

To investigate the effects of α₂-adrenergic agonists on perioperative mortality and cardiovascular complications in adults undergoing surgery.

Methods

MEDLINE (1966 to May 2002), EMBASE (1980 to May 2002), the Cochrane Clinical Trials Register, the Science Citation Index, and bibliographies of included articles were searched without language restriction. Randomized trials comparing preoperative, intraoperative, or postoperative (first 48 hours) administration of clonidine, dexmedetomidine, or mivazerol with controls were included. Studies had to report any of the following outcomes: mortality, myocardial infarction, ischemia, or supraventricular tachyarrhythmia. Treatment effects were calculated using the fixed-effects model. Heterogeneity was assessed using the Q test.

Results

Twenty-three trials comprising 3395 patients were included. Overall, α₂-adrenergic agonists reduced mortality (relative risk [RR] = 0.64; 95% confidence interval [CI]: 0.42 to 0.99; P = 0.05) and ischemia (RR = 0.76; 95% CI: 0.63 to 0.91; P = 0.003) significantly. They also reduced mortality (RR = 0.47; 95% CI: 0.25 to 0.90; P = 0.02) and myocardial infarction (RR = 0.66; 95% CI: 0.46 to 0.94; P = 0.02) during vascular surgery. During cardiac surgery, α₂-adrenergic agonists reduced ischemia (RR = 0.71; 95% CI: 0.54 to 0.92; P = 0.01) and were associated with trends toward lower mortality (RR = 0.49; 95% CI: 0.12 to 1.98; P = 0.3) and a reduced risk of myocardial infarction (RR = 0.83; 95% CI: 0.35 to 1.96; P = 0.7).

Conclusion

Alpha-2 adrenergic agonists reduce mortality and myocardial infarction following vascular surgery. During cardiac surgery, they reduce ischemia and may also have effects on mortality and myocardial infarction. Large randomized trials are needed to evaluate these agents during cardiac and vascular surgery.

Section snippets

Methods

This review adhered to the recommendations of the Quality of Reporting of Meta-analyses (QUOROM) group (15).

Results

Twenty-three studies comprising 3395 patients were included (Table 1; Figure 1). A list of excluded studies is available from the authors.

Ten studies involved cardiac surgery, eight involved vascular noncardiac surgery, and three involved nonvascular noncardiac surgery (Table 1). One noncardiac surgery study (13) presented subgroup-specific results for both vascular and nonvascular procedures. Fifteen studies assessed clonidine, six assessed dexmedetomidine, and two assessed mivazerol.

Discussion

Our results show that α₂-agonists reduce perioperative mortality and myocardial ischemia following cardiac and noncardiac surgery. No single treatment regimen was clearly superior. These perioperative benefits may depend largely on the surgical procedure involved, with the largest benefits observed in patients undergoing vascular and cardiac surgery. Compared with a prior systematic review of perioperative clonidine (14), our meta-analysis included all commonly used α₂-agonists, used a more

Acknowledgements

We thank the following authors for providing additional information regarding their publications: Dr. M. Fischler (Hôpital Foch, Suresnes, France), Dr. R. M. Venn (Worthing Hospital, West Sussex, United Kingdom), Dr. R. M. Grounds (St George’s Hospital, London, United Kingdom), Dr. H. M. Loick (Marien-Hospital Euskirchen, Euskirchen, Germany), Dr. I. Matot (Hadassah Hebrew University Medical Center, Jerusalem, Israel), Dr. P. Myles (Alfred Hospital, Melbourne, Victoria, Australia), Dr. M.

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^☆: Dr. Wijeysundera is the recipient of the Dr. Allan K. Laws Clinician Scientist Fellowship from the University of Toronto, Ontario, Canada.

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Special articleAlpha-2 adrenergic agonists to prevent perioperative cardiovascular complications:: A meta-analysis☆

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Acknowledgements

Ann Thorac Surg

Lancet

Control Clin Trials

Control Clin Trials

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

Br J Anaesth

Lancet

Lancet

Perioperative myocardial infarction after coronary artery bypass surgery. Clinical significance and approach to risk stratification

Circulation

Perioperative cardiac morbidity

Anesthesiology

Long-term cardiac prognosis following noncardiac surgery. The Study of Perioperative Ischemia Research Group

JAMA

Mechanism of plasma catecholamine increases during surgical stress in man

J Clin Endocrinol Metab

Should we all have a sympathectomy at birth? Or at least preoperatively?

Anesthesiology

Clonidine reduces sympathetic activity but maintains baroreflex responses in normotensive humans

Anesthesiology

Premedication with oral and transdermal clonidine provides safe and efficacious postoperative sympatholysis

Anesth Analg

Clonidine prevents the sympathetic initiation and aggravation of poststenotic myocardial ischemia

J Cardiovasc Pharmacol

Perioperative sympatholysisbeneficial effects of the α2-adrenoceptor agonist mivazerol on hemodynamic stability and myocardial ischemia

Anesthesiology

Effects of perioperative dexmedetomidine infusion in patients undergoing vascular surgery. The Study of Perioperative Ischemia Research Group

Anesthesiology

ACC/AHA guideline update on perioperative cardiovascular evaluation for noncardiac surgery

Circulation

Effect of mivazerol on perioperative cardiac complications during non-cardiac surgery in patients with coronary heart diseasethe European Mivazerol Trial (EMIT)

Anesthesiology

Efficacy of clonidine for prevention of perioperative myocardial ischemiaa critical appraisal and meta-analysis of the literature

Anesthesiology

Statistical aspects of the analysis of data from retrospective studies of disease

J Natl Cancer Inst

Bias in meta-analysis detected by a simple, graphical test

BMJ

Can clonidine, enoximone, and enalaprilat help to protect the myocardium against ischaemia in cardiac surgery?

Heart

Special article
Alpha-2 adrenergic agonists to prevent perioperative cardiovascular complications:: A meta-analysis☆

Perioperative sympatholysisbeneficial effects of the α₂-adrenoceptor agonist mivazerol on hemodynamic stability and myocardial ischemia