Author's reply to Grocott: Risk of cardiac ischaemia in patients without α-receptor blockade for phaeochromocytoma surgery

Abstract

Editor—We thank Prof Grocott for his comments.1Grocott HP Safety assessments in the avoidance of preoperative a-receptor blockade in phaeochromocytoma surgery: the pitfalls of a zero numerator.Br J Anaesth. 2017; 119: 545-546Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The author questions whether the incidence of perioperative myocardial infarction in patients with phaeochromocytoma without perioperative α-receptor blockade is truly zero, without taking serial troponin measurements. It is true, that we only looked at clinical performance over several days and did not find any apparent signs of haemodynamic instability or clinical symptoms of myocardial ischaemia.2Groeben H Nottebaum BJ Alesina PF Traut A Neumann HP Walz MK Perioperative alpha-receptor blockade in phaechromocytoma surgery: an observational case series.Br J Anaesth. 2017; 118: 182-189Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar However, with a minimal difference in maximal blood pressure compared with patients with perioperative α-receptor blockade, there is no rationale to believe that patients with α-receptor blockade differ and do not have the same incidence of myocardial ischaemia. Furthermore, we know from several studies with ischaemic heart disease that hypotension can trigger myocardial ischaemia as well.3Vidal-Petiot E Ford I Greenlaw N et al.Cardiovascular event rates and mortality according to achieved systolic and diastolic blood pressure in patients with stable coronary artery disease: an international cohort study.Lancet. 2016; 388: 2142-2152Abstract Full Text Full Text PDF PubMed Scopus (287) Google Scholar 4Al Saleh AS Alhabib KF Alsheik-Ali AA et al.Predictors and impact of in-hospital recurrent myocardial infarction in patients with acute coronary syndrome: Findings from Gulf RACE-2.Angiology. 2017; 68: 508-512Crossref PubMed Scopus (4) Google Scholar Concerning hypotension, defined as mean arterial pressure below 60 mm Hg, we found a significantly higher incidence in patients with α-receptor blockade. Therefore, it might be argued that the risk and incidence of “silent ischaemia” is even higher in patients with α-receptor blockade. Unfortunately, we cannot provide troponin plasma concentration in either group. We do not believe that the assumption is justified that the incidence of ischaemic episodes is higher in patients without α-receptor blockade. The only perioperative complication we observed was an ischaemic stroke on the third postoperative day, which was more likely as a result of hypotension than to hypertension. Concerning perioperative safety, we can definitely not guarantee that there will be no complication in patients without α-receptor blockade, and we cannot in patients with α-receptor blockade. We do know from the literature and ongoing international data acquisition, that there is a certain rate of morbidity and mortality in phaeochromocytoma surgery. In their last paragraph the authors mention the difficulty in some countries of obtaining an α-receptor blocker, which we agree is very critically important in many areas of medicine. We thank the authors for their comments on our case series. Our intention is not to ban α-receptor blockers in general, which can be very helpful as a therapeutic agent rather than a prophylactic drug, but to question their obligatory use, demanded by international guidelines. These guidelines have medico-legal implications and we opt to open up these guidelines and leave it to every centre to use or not to use a perioperative prophylaxis. None declared.