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Is There Any Reason to Withhold α2 Agonists from Patients with Coronary Disease during Surgery?

Quintin, Luc M.D., Ph.D*; Ghignone, Marco M.D., F.R.C.P.C

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To the Editor:—

London et al.1 and Kertai et al.2 are to be commended for their review on β blockers and outcome. As an alternative to β blockers, after introduction of α2 agonists in human anesthesia,3 several large-scale trials or meta-analyses suggested that α2 agonists decrease myocardial ischemia/infarction or mortality after cardiovascular surgery.4–6 Another meta-analysis reported that β blockers decreased cardiac death from 3.9% to 0.8% and that α2 agonists decreased cardiac death from 2.3% to 1.1%.7 By contrast, another point of view suggests that β blockers and α2 agonists cannot carry a relative risk reduction higher than 25%.8 Authors suggested that α2 agonists are an alternative when asthma/hyperreactive airway,1,2,7 atrioventricular block,1,2,7 or decompensated systolic failure7 are present. In fact, α2 agonists reduce bronchoconstriction in human9 and dog10 models, and clonidine increases stroke index in patients with cardiac failure who have a New York Heart Association classification of III or IV11,12: The sicker the patient is, the larger the systolic performance seems to increase.13,14 A recent editorial15 stated that the “53% reduction in overall mortality [due to α2 agonists is] actually …more impressive that was has been found in the pooled β-blocker studies.” Given the fewer contraindications of α2 agonists as compared with β blockers, we surmise that clinicians could consider α2 agonists as first-line drugs. Given the recent availability of intravenous α2 agonists on the North American market, administration of α2 agonists is simple: oral or intravenous or down the nasogastric tube or rectally. Appropriate reduction in anesthetic doses and volume loading in coronary/hypertensive patients presenting for major cardiovascular surgery3 or major noncardiac surgery have been delineated. As suggested,7,15 α2 agonists and β blockers should be directly compared. Conversely, they may be combined to achieve maximal favorable effects.
Luc Quintin M.D., Ph.D.,*
Marco Ghignone M.D., F.R.C.P.C.
* Physiology, School of Life Sciences, Lyon, France, and Columbia Hospital, West Palm Beach, Florida.
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