A Recipe for Perioperative Cardioprotection: What Matters Most? The Ingredients or the Chef?

The question of what is the ideal anesthetic for patients with cardiovascular disease has been debated for nearly three decades, and similarly to the case for the use of perioperative beta blockers, the answer appears to be increasingly enigmatic. In the current issue of the Journal, Buse et al(1) report the results of a randomized clinical trial to evaluate the effects of the volatile anesthetic sevoflurane versus the intravenous anesthetic propofol on the incidence of myocardial ischemia in 385 patients with known coronary artery disease or with two or more risk factors for coronary artery disease undergoing non-cardiac surgery. Using continuous electrocardiography and troponin T plasma concentrations as the composite primary endpoint of the study, the incidence of myocardial ischemia was similar in both groups (sevoflurane: 40.8%; propofol: 40.3%); calling into question the current American College of Cardiology/American Heart Association guidelines recommending the use of volatile anesthetics for patients at cardiovascular risk who are undergoing non-cardiac surgery(2).