Варіабельність ритму серця у хворих з ішемічною хворобою серця: вплив епідуральної анестезії

Objective. The paper describes the changes in the heart rate variability (HRV) under the influence of epidural anesthesia (EA) in patients with coronary artery disease (CAD) and in practically healthy individuals undergoing surgery for the inguinal hernia. Peculiarities of influence of bupivacaine and ropivacaine on the dynamics of changes of spectral and statistical indicators of a HRV in the perioperative period in the active and passive observation periods have been established.Setting. Lviv Municipal Clinical Emergency Hospital.Patients. Thirty seven males who were operated for the inguinal hernia with EA were examined. Group I (23 patients, mean age 56.61 ± 1.58 years) with CAD, stable angina (NYHA I–III) was randomly divided in to 2 subgroups — subgroup I (12 patients) — persons who had EA under local anesthetic (LA) bupivacaine (0.5%), and subgroup II (11 patients), in which LA was ropivacaine (0.75%). The group II included 14 healthy individuals (mean age 49.07 ± 2.07 years), who were randomly divided into 2 subgroups, in which EA was performed using bupivacaine (subgroup I, 7 patients) and ropivacaine (subgroup II, 7 persons).The control group were healthy volunteers — 12 men aged 35 to 65 years (mean age 54.06 ± 3.74 years), in which the absence of CAD confirmed by exercise test (bicycle ergometer). Patients of the control group underwent echocardiography, Holter ECG monitoring with determination of statistical (time) and frequency (spectral) HRV, biochemical research.Results. We have identified features of HRV in the active and passive observation periods depending on LA — bupivacaine and ropivacaine.The active period of observation revealed more pronounced increasing in sympathetic influence on heart rhythm in patients who were exposed to ropivacaine. LF value was higher at 1.57 % in group I (subgroup II) and 32.42 % — in group II (subgroup II), compared with two subgroups of patients, which were administered bupivacaine. LF/HF ratio in subgroups of ropivacaine also was higher than the corresponding rates in subgroups of bupivacaine — at 3.39 % (group I) and 39.10 % (group II). Thus, patients of subgroups of ropivacaine had reduced sympathetic tone of vegetative nervous system less pronounced and had higher sympathotonia.In all patients the growth activity of the parasympathetic nervous system was revealed, as described above. By analyzing this process based on the used LA, we have found that in patients of group I in the active period of monitoring HF-value in ropivacaineи subgroup was slightly (by 1.44 %) higher than the corresponding value in bupivacaine subgroup (p = 0.4567), and in the group II HF parameters in the subgroup of ropivacaine were on 9.71 % lower than the values in the subgroup of bupivacaine (p = 0.0587). These data indicate the ability of ropivacaine to inhibit vagal influences in patients without CAD and the lack of such in patients with CAD.In subgroups of patients to which bupivacaine was administered, the highest in the daytime period was the value of VLF. So bupivacaine, compared with ropivacaine, more intensively increased humoral influences on HR.We have not noted a significant difference between the levels of RMSSD and pNN50 in the application of both anesthetics in group II, but the value of SDNNi in ropivacaine subgroup was significantly lower (by 19.91 %) than in group of bupivacaine, confirming the ability of the ropivacaine to noticeably reduce vagal activity in persons without CAD.Analyzing the dynamics in spectral parameters of HRV under a different LA in passive period of monitoring, significant differences in two subgroups in patients with CAD was not found.At the same time in persons without CAD (group II) a significant decreasing in the values of HF and VLF with increa­sing value of LF/HF was observed, which confirms the ability of the ropivacaine to reduce activity of humoral effects on HR and depress the tone of the parasympathetic branch of HRV in this categories of patients.Statistical parameters of HRV in passive period also indicated the less pronounced ability of ropivacaine to reduce the parasympathetic activity of vegetative nervous system in patients with CAD.Simultaneously, we again had marked depressive effect of ropivacaine on parasympathetic tone in patients without CAD. In this group a tendency to the restoring of circadian rhythm of HR regulation was better (taking into account the dynamics of HRV during the day depending on the applied anesthetic).Conclusions. Ropivacaine, compared with bupivacaine, less effectively reduces the sympathetic activity in all patients, mo­derate increases parasympathetic tone in patients with CAD and reduces it in persons without pathology of the cardiovascular system.Considering the benefits of the ropivacaine on the autonomic balance of a heart activity in patients with CAD it can be regar­ded as the drug of choice for EA during surgical interventions for inguinal hernia in these patients.В статье описаны изменения вариабельности ритма сердца под влиянием эпидуральной анестезии у пациентов с ишемической болезнью сердца и практически здоровых лиц, которые подверглись оперативным вмешательствам по поводу паховых грыж. Выявлены особенности влияния бупивакаина и ропивакаина на динамику изменений спектральных и статистических показателей вариабельности ритма сердца в периоперационный период, проанализирован их характер в активный и пассивный периоды наблюдения.У статті описано зміни варіабельності ритму серця під впливом епідуральної анестезії в пацієнтів з ішемічною хворобою серця і практично здорових осіб, які зазнали оперативних втручань із приводу пахових гриж. Виявлено особливості впливу бупівакаїну та ропівакаїну на динаміку змін спектральних і статистичних показників варіабельності ритму серця в періопераційний період, проаналізовано їх характер в активний і пасивний періоди спостереження