Clinical characteristics of perioperative coronary spasm: Reviews of 115 case reports in Japan

Purpose. Factors affecting perioperative development of coronary spasm have not been elucidated. A number of case reports describing perioperative coronary spasm have appeared in Japanese anesthesia journals, mostly published in Japanese. The purpose of this study was to investigate the contributing factors affecting perioperative coronary artery spasm by reviewing the published articles. Methods. Reports were identified by using Medline database (1968-1998) or by manually searching nonindexed Japanese journals. The clinical characteristics of perioperative coronary spasm were analyzed in 115 patients who developed coronary artery spasm during the perioperative period. Results. The mean age of the patients was 64 ± 9 years (range, 36 to 87 years). There were 97 men (84%) and 18 women (16%). Preoperative risk factors included hypertension (27%), angina pectoris (27%), cigarette smoking (13%), and diabetes mellitus (11%). The attack was related to inadequate depth of general anesthesia (23%), use of vasopressors (22%), vagal reflex (19%), administration of drugs other than vasopressors (17%), and epidural block (15%). About 85% of patients showed no ischemic abnormality on the preoperative electrocardiogram, whereas 56% had significant coronary stenosis on postoperative coronary arteriography. Coronary spasm tended to occur in patients under inhalation anesthesia combined with epidural block. Nitrates alleviated the episode in the majority of cases, whereas defibrillation and cardiac massage were required in 19% of patients. No deaths were reported. Conclusion. Perioperative coronary spasm is prevalent in elderly male patients with coronary risk factors who undergo abdominal or thoracic surgery under inhalational anesthesia combined with epidural anesthesia. Instability of the autonomic nervous system and/or vascular hyperreactivity may be the underlying pathogenic mechanisms of perioperative coronary spasm.