Epidural Analgesia Reduces Postoperative Myocardial Infarction: A Meta-Analysis

Postoperative cardiac morbidity and mortality continue to pose considerable risks to surgical patients. Postoperative epidural analgesia is considered to have beneficial effects on cardiac outcomes. The use in high-risk cardiac patients remains controversial. No study has shown that postoperative epidural analgesia decreases postoperative myocardial infarction (PMI) or death. All studies are underpowered to show such a result, and the cost of conducting a large trial is prohibitive. We performed a metaanalysis to determine whether postoperative epidural analgesia continued for more than 24 h after surgery reduces PMI or in-hospital death. The available databases were searched for randomized controlled trials of epidural analgesia that was extended at least 24 h into the postoperative period. The search yielded 17 studies, of which 11 were randomized controlled trials comprising 1173 patients. Metaanalysis was conducted by using the fixed-effects model, calculating both an odds ratio and a rate difference. Postoperative epidural analgesia resulted in better analgesia for the first 24 h after surgery. The rate of PMI was 6.3%, with lower rates in the Epidural group (rate difference, −3.8%; 95% confidence interval [CI] −7.4%, −0.2%;P = 0.049). The frequency of in-hospital death was 3.3%, with no significant difference between Epidural and Nonepidural groups (rate difference, −1.3%; 95% CI, −3.8%, 1.2%, P = 0.091). Subgroup analysis of postoperative thoracic epidural analgesia showed a significant reduction in PMI in the Epidural group (rate difference, −5.3%; 95% CI, −9.9%, −0.7%;P = 0.04).

[1]  R V Patel,et al.  Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. , 1991, Anesthesia and analgesia.

[2]  K. Reinhart,et al.  Effects of Thoracic Epidural Anesthesia on Systemic Hemodynamic Function and Systemic Oxygen Supply‐Demand Relationship , 1989, Anesthesia and analgesia.

[3]  C. Meinert,et al.  Perioperative Morbidity in Patients Randomized to Epidural or General Anesthesia for Lower Extremity Vascular Surgery , 1993, Anesthesiology.

[4]  R. Koff,et al.  Meta-analysis, decision analysis, and cost-effectiveness analysis. Methods for quantitative synthesis in medicine , 1995 .

[5]  R. Neff,et al.  Epidural Anesthesia and Analgesia in High‐risk Surgical Patients , 1987, Anesthesiology.

[6]  U. Bothner,et al.  [Patient-controlled analgesia versus epidural analgesia using bupivacaine or morphine following major abdominal surgery. No difference in postoperative morbidity]. , 1991, Der Anaesthesist.

[7]  Anthony Rodgers,et al.  Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials , 2000, BMJ : British Medical Journal.

[8]  A. Gelb,et al.  Myocardial Infarction after Noncardiac Surgery , 1998, Anesthesiology.

[9]  N. Laird,et al.  Meta-analysis in clinical trials. , 1986, Controlled clinical trials.

[10]  J. Gold,et al.  Surveillance for postoperative myocardial infarction after noncardiac operations. , 1988, Surgery, gynecology & obstetrics.

[11]  L. Way,et al.  Long-term cardiac prognosis following noncardiac surgery , 1992 .

[12]  R. Collins,et al.  Intravenous and intracoronary fibrinolytic therapy in acute myocardial infarction: overview of results on mortality, reinfarction and side-effects from 33 randomized controlled trials. , 1985, European heart journal.

[13]  K. McPherson,et al.  Secondary prevention of vascular disease by prolonged antiplatelet treatment , 1988, British medical journal.

[14]  S. Roe,et al.  Postoperative pulmonary complications and morbidity after abdominal aneurysmectomy: a comparison of postoperative epidural versus parenteral opioid analgesia. , 1996, The American surgeon.

[15]  W. Cassel,et al.  Combined epidural and general anesthesia in aortic surgery. , 1990, The Journal of cardiovascular surgery.

[16]  J. Sear,et al.  Myocardial Ischemia in Untreated Hypertensive Patients: Effect of a Single Small Oral Dose of a Beta‐Adrenergic Blocking Agent , 1988, Anesthesiology.

[17]  T. Riles,et al.  The value of silent myocardial ischemia monitoring in the prediction of perioperative myocardial infarction in patients undergoing peripheral vascular surgery. , 1989, Journal of vascular surgery.

[18]  M. Breslow,et al.  The Effects of Different Anesthetic Regimens on Fibrinolysis and the Development of Postoperative Arterial Thrombosis , 1993, Anesthesiology.

[19]  N. Breslow,et al.  Statistical methods in cancer research: volume 1- The analysis of case-control studies , 1980 .

[20]  M. Davies,et al.  Combined Epidural and General Anaesthesia versus General Anaesthesia for Abdominal Aortic Surgery: A Prospective Randomised Trial , 1993, Anaesthesia and intensive care.

[21]  L. Fleisher,et al.  Postoperative myocardial ischemia: etiology of cardiac morbidity or manifestation of underlying disease? , 1995, Journal of clinical anesthesia.

[22]  G. Moneta,et al.  Late survival after perioperative myocardial infarction complicating vascular surgery. , 1994, Journal of vascular surgery.

[23]  E. Cook,et al.  Correlation Between Preoperative Ischemia and Major Cardiac Events After Peripheral Vascular Surgery , 1989, The New England journal of medicine.

[24]  F. Mosteller,et al.  The Comparative Effects of Postoperative Analgesic Therapies on Pulmonary Outcome: Cumulative Meta-Analyses of Randomized, Controlled Trials , 1998, Anesthesia and analgesia.

[25]  D. N. Buckley,et al.  Epidural morphine reduces the riskof postoperative myocardial ischaemia in patients with cardiac risk factors , 1993, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[26]  T. Ruddy,et al.  Perioperative ischaemia in aortic surgery: combined epidural/ general anaesthesia and epidural analgesia vs general anaesthesia andiv analgesia , 1996, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[27]  P. Couture,et al.  Epidural Analgesia and Intravenous Patient-Controlled Analgesia Result in Similar Rates of Postoperative Myocardial Ischemia After Aortic Surgery , 1997, Anesthesia and analgesia.

[28]  N. Breslow,et al.  Statistical methods in cancer research. Vol. 1. The analysis of case-control studies. , 1981 .

[29]  J. Stothard,et al.  Thromboprophylaxis and death after total hip replacement. , 1997, The Journal of bone and joint surgery. British volume.

[30]  A R Jadad,et al.  Assessing the quality of reports of randomized clinical trials: is blinding necessary? , 1996, Controlled clinical trials.

[31]  S. Zarich,et al.  Cardiac Outcome after Peripheral Vascular Surgery: Comparison of General and Regional Anesthesia , 1996, Anesthesiology.

[32]  H. Kehlet,et al.  A Controlled Study on the Effect of Epidural Analgesia with Local Anaesthetics and Morphine on Morbidity after Abdominal Surgery , 1985, Acta anaesthesiologica Scandinavica.

[33]  F. Veith,et al.  Epidural versus general anesthesia for infrainguinal arterial reconstruction. , 1991, Journal of vascular surgery.

[34]  S. Cotev,et al.  Importance of long-duration postoperative ST-segment depression in cardiac morbidity after vascular surgery , 1993, The Lancet.

[35]  allace,et al.  EFFECT OF ATENOLOL ON MORTALITY AND CARDIOVASCULAR MORBIDITY AFTER NONCARDIAC SURGERY , 2000 .

[36]  M. Lema,et al.  Postoperative Myocardial Ischemia: Epidural versus Intravenous Patient-controlled Analgesia: A Pilot Project , 1994, Regional Anesthesia & Pain Medicine.

[37]  P. Couture,et al.  Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of myocardial ischemia after aortic surgery. , 1998 .

[38]  B. Kavanagh,et al.  Epidural Bupivacaine-Morphine Analgesia versus Patient-controlled Analgesia following Abdominal Aortic Surgery: Analgesic, Respiratory, and Myocardial Effects , 1998, Anesthesiology.

[39]  Perioperative cardiac morbidity , 1990, Anesthesiology.

[40]  R. Peto,et al.  Beta blockade during and after myocardial infarction: an overview of the randomized trials. , 1985, Progress in cardiovascular diseases.