Zusammenfassung
Die perioperative Organfunktionsstörung ist ein Ereignis, dessen Inzidenz zunimmt. Besonders kardiale Ereignisse haben eine große Bedeutung: für die medizinische Betreuung der Patienten und aus ökonomischer Sicht. Hier müssen alle Anstrengungen unternommen werden, um solche Ereignisse zu verhindern. Neben allgemeinen Maßnahmen wie Stressabschirmung, ausreichende Analgesie und suffiziente Volumentherapie stehen die medikamentöse Therapie mit Beta-Adrenozeptor-Antagonisten und HMG-CoA-Reduktase-Inhibitoren im Vordergrund. Beide Medikamentengruppen zeigen pleiotrope Effekte auf die kardiovaskuläre Funktion und reduzieren so die kardiale Morbidität und Mortalität. Daher sollte nach den aktuellen Empfehlungen eine chronische Therapie auf jeden Fall fortgesetzt werden. Ein Neubeginn einer Beta-Blocker-Therapie sollte nur unter individueller Nutzen-Risiko-Abwägung erfolgen, weil eine große aktuelle Studie sowie eine Metaanalyse ein insgesamt schlechteres Outcome bei neu begonnener Beta-Blocker-Therapie im Vergleich zu Plazebo zeigten. Wenn möglich sollte ein solcher Patient solange verschoben werden, bis eine einschleichende Therapie unter Berücksichtigung der Herzfrequenz und des Blutdrucks etabliert werden konnte. Unter Berücksichtigung der aktuellen Datenlage ist auch ein Neubeginn einer perioperativen Statintherapie bei gefäßchirurgischen Patienten zu empfehlen. Für andere Patientengruppen liegen allerdings noch keine Daten vor.
Abstract:
The number of patients with limited organ function is steadily increasing due to the aging of the population. Consequently, a growing number of patients needing surgery is accompanied by serious comorbidities. These patients are at high risk of perioperative organ dysfunction. In this context cardiac events (e.g. cardiac arrhythmias, angina or myocardial infarction) play a major role with significant impact on postoperative care, long term outcome and economic sequelae. Thus, anaesthesiologists must prevent such events in the perioperative period. Besides general measures such as adequate analgesia, protection from stressful events and sufficient volume replacement, medical intervention with beta-blockers or HMG-CoA-reductase-inhibitors (statins) are necessary to reduce the incidence of perioperative cardiac events. Both beta-blockers and HMG-CoA-reductase-inhibitors are known to exhibit pleiotropic effects (defined as additional cardioprotective effects) besides the primary blockade of the beta-adrenergic receptor or the inhibition of the synthesis of serum cholesterol, respectively. Both groups of drugs improve cardiac function, decrease inflammatory response, decrease activation of blood coagulation and stabilize endothelial plaques.
Based on the current literature the following recommendations are published concerning the perioperative administration of beta-blockers: (i) Patients who are on beta-blockers on a regular basis following guidelines concerning chronic treatment of cardiovascular diseases should continue this medication throughout the perioperative period; (ii) a sufficient indicator of an adequate therapy is the baseline heart rate. It should not exceed 60–70bpm at rest; (iii) the Revised Cardiac Risk Index (RCRI) is a widely accepted score to estimate the patient's perioperative cardiac risk; (iv) patients with a RCRI ≥3 should not be scheduled for routine surgery without sufficient beta-adrenergic-receptor blockade; (v) in patients at high cardiac risk based on the RCRI who are scheduled for emergency surgery beta-blocker-therapy should not be initiated de novo perioperatively. However, for perioperative treatment of tachycardia or hypertension beta-blockers are the drug of first choice.
Concerning perioperative statin-therapy the following recommendations are suggested: (i) chronic statin-therapy should be continued throughout surgery and the perioperative period; (ii) in patients without chronic statin-therapy scheduled for vascular surgery this treatment should be started perioperativly; (iii) no data is available concerning other patient populations; (iv) if statin-therapy is indicated it should be started independently from baseline serum LDL-C-concentration; (v) side effects of statin-therapy are rare and usually not live threatening, thus treatment is considered to be without serious risks to the patient.
Kernaussagen
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Eine Million Patienten müssen sich schätzungsweise pro Jahr bei einer zugrundeliegenden KHK einer Operation unterziehen. Die Inzidenz von perioperativen kardialen Ereignissen liegt bei 10–15 % und stellt ein erhebliches medizinisches und volkswirtschaftliches Problem dar.
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Diese Ereignisse sollten verhindert werden durch allgemeine Maßnahmen (Optimierung des Verhältnisses von Sauerstoffangebot zu Sauerstoffverbrauch) und Medikamente.
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Als günstig für das kardiovaskuläre Outcome dieser Risikopatienten haben sich unter bestimmten Bedingungen Beta-Blocker und Statine erwiesen.
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Der Revised-Cardiac-Risk-Index (RCRI) ist im anästhesiologischen Sinne ein praktikabler Score zur Risikoeinschätzung: Mit 6 einfachen Kriterien während der Prämedikation ist er problemlos erfassbar und eine validierte und verbreitete Basis, um die perioperative Versorgung von Risikopatienten zu planen.
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Beta-Blocker wurden trotz umstrittener Studienergebnisse lange Zeit perioperativ auch neu verordnet. Jüngste Ergebnisse einer großen randomisierten Multicenterstudie (POISE) zeigten unter einer neu begonnenen Therapie mit Beta-Blockern eine erhöhte Gesamtmortalität – insbesondere durch vermehrte Schlaganfälle.
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Beta-Blocker werden perioperativ eingesetzt: zur Fortführung einer chronischen Therapie, einschleichend dosiert bei Neubeginn (mehrere Wochen, RCRI ≥ 3) und therapeutisch bei Tachykardie nach Ausschluss anderer Kausalitäten.
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Alternativ oder ergänzend zu Beta-Blockern gibt es HMG-CoA-Reduktase-Inhibitoren (Statine). Aufgrund pleiotroper Effekte (unabhängig von der Fettstoffwechselstörung) beeinflussen sie das kardiale Outcome von Risikopatienten günstig.
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Günstige Effekte einer perioperativen Therapie zeigten sich auch bei kurzfristiger Einnahme, unabhängig von der LDL-C-Serum-Konzentration vor Therapiebeginn.
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Zwei Tatsachen limitieren die Studienergebnisse zur perioperativen Statintherapie: Es gibt nur Daten zu Patienten mit einem gefäßchirurgischen Eingriff, und es fehlen prospektive, randomisierte, plazebokontrollierte Studien.
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Statine haben ein günstiges Nebenwirkungsprofil. Schwerwiegende Komplikationen sind selten.
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PD Dr. med. Robert Hanß
PD Dr. med. Berthold Bein
eMail: hanss@anaesthesie.uni-kiel.de
eMail: bein@anaesthesie.uni-kiel.de
