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When you have a difficult problem in medicine the first thing to do is identify all the possible etiologies. Then correct each problem and see if it helps. A very large number of therapeutic trials have been conducted of possible medical therapies for myocardial ischemia. At the end of all this work two have been proven to work: Beta blockers and Clonidine. Of the other tested agents, the studies for dexmedetomidine were stopped. Mivazerol had some benefits in secondary analysis but development was stopped. Diltiazem and nifedipine increase risk in outpatients with coronary artery disease and have no benefit in surgical patients. Acadesine reduced risk in cardiac patients but is not clinically available. Aspirin and coumadin trials were stopped. Draflazine was not beneficial. Sufentanyl was not beneficial and required prolonged postoperative ventilation. The epidural/PCA trials are mixed. Desflurane increased risk. Isoflurane, sevoflurane, and propofol had no effects. Nitroglycerine and RSR-13 had no proven benefit. L-Arginine is being studied. So after a tremendous amount of work you have two proven therapies both of which are inexpensive, generic drugs, proven to reduce the risk of death in patients undergoing non-cardiac surgery.
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