Epidural infusion of bupivacaine and fentanyl reduces perioperative myocardial ischaemia in elderly patients with hip fracture--a randomized controlled trial

BACKGROUND

Perioperative myocardial ischaemia is an important risk factor for cardiac morbidity and mortality after noncardiac surgery. The impact of analgesic management on the incidence and severity of cardiac ischemia was studied in 77 elderly patients undergoing surgical treatment of traumatic hip fracture.

METHODS

After hospital admission and written consent, patients were randomised to conventional analgesic regimen (intramuscular oxycodone, OPI group) or continuous epidural infusion of bupivacaine/fentanyl (EPI group). The analgesic regimens were started preoperatively. Patients were operated under spinal anaesthesia and the treatments were continued three days postoperatively. ECG was continuously recorded. ST segment depression of > or = 0.1 mV or elevation of > or = 0.2 mV lasting > or = 1 min were considered as ischaemic episodes. Nocturnal arterial oxygen saturation (SaO2) was recorded perioperatively, and subjective pain was assessed every morning using a visual analogue scale (VAS).

RESULTS

Fifty-nine (OPI 30, EPI 29) patients were evaluable for efficacy. Thirteen patients (43%) in the OPI and 12 patients (41%) in the EPI group had ischaemic episodes (NS). However, significantly more patients in the OPI group had ischaemic episodes during the surgery (8 vs. 0 in the EPI group, P=0.005). The median (quartal deviation) total ischaemic burden (i.e. integral of ST-change vs. time) in patients with ischaemic episodes was ten times larger in the OPI group (340 [342] mm x min) compared with the EPI group (30 [36] mm x min) (P=0.002). There were no significant differences between the groups in average heart rates or in heart rates at the start of ischaemic episodes or in maximal heart rates during the attacks. Average nocturnal SaO2 was similar in the two groups and there were no differences in the number of hypoxaemic (SaO2<90%) episodes. Preoperatively there were no differences in subjective pain, but postoperative and average perioperative VAS scores for pain were almost 40% lower in the EPI group (P=0.006). Perioperative myocardial infarctions were not detected.

CONCLUSIONS

Continuous epidural bupivacaine/fentanyl analgesic regimen, started preoperatively, reduces the amount of myocardial ischaemia in elderly patients with hip fracture.

Alarmingly high occurrence and case fatality of acute coronary heart disease events in Estonia: results from the Tallinn AMI register 1991-94

OBJECTIVE

The purpose of this study was to produce stable estimates for the incidence, attack and mortality rates and case fatality of acute myocardial infarction (AMI) in Tallinn, the capital of Estonia.

RESEARCH DESIGN AND METHODS

The Tallinn AMI register covers the population aged 25-64 years and official residents of Tallinn. The register follows the WHO MONICA project protocols in the data collection and diagnostic evaluation of the suspected AMI events and CHD death.

RESULTS

Age-standardized annual incidence, attack rate and mortality in men aged 35-64 years were high, varying from (per 100000 per year) 352, 499 and 208, respectively, in 1991 to 438, 628 and 317, respectively, in 1993. In addition, in women, annual incidence, attack rate and mortality were high, varying from (per 100000 per year) 82, 100 and 31, respectively, in 1991 to 110 and 142 in 1993 for the incidence and attack rate, and to 61 in 1992 for mortality. The percentage of out-of-hospital coronary death (sudden death) increased in men from 33 to 52% and in women from 24 to 42% during 1991-94, and the 28-day case fatality increased in men from 42 to 58%, and in women from 32 to 50%. In Tallinn, women with AMI were treated as actively as men with invasive treatment (thrombolysis, angioplasty, bypass surgery) during the acute phase of MI.

CONCLUSIONS

The incidence, attack rate and mortality of AMI were high in both men and women in Tallinn. The high 28-day case fatality observed was primarily due to the high proportion of out-of-hospital deaths.

Acute myocardial infarction in Estonia: first results from the Tallinn AMI Register

The acute myocardial infarction (AMI) register of Tallinn, the capital of Estonia, started in 1990. The register follows methodology recommended by the WHO MONICA Project for the registration of coronary events. By standardizing its procedures with the FINMONICA AMI register, the Tallinn AMI register aims at producing data comparable with those of the centers participating in the WHO MONICA Project. This article presents incidence, attack rates, and mortality rates of AMI in Estonia during the first year of registration in Estonians and non-Estonians (mostly Russians) of the study area. The total number of registered AMI events was 493 among men and 117 among women. The age-standardized mortality from AMI (per 100,000 population) was 249 (95% confidence interval, 201-297) in Estonian men and 234 (189-279) in non-Estonian men. In women the corresponding rates were 35 (20-50) and 39 (23-55), respectively. The incidence and attack rate of AMI were not different in Estonians and non-Estonians. The incidence of AMI seems to be relatively high in international comparison. The registration period of our study is thus far rather short, but it is the first investigation of the incidence of AMI in Estonia based on standardized data collection procedures. This study provides a basis for the development of surveillance of cardiovascular disease in Estonia.