European Journal of Cardiovascular Medicine

Anesthetic induction plays a pivotal role in ensuring hemodynamic stability for patients with pre existing cardiac disease undergoing non cardiac surgery. The choice of induction agent is particularly significant, as agents such as etomidate and propofol exert distinct cardiovascular effects in this high risk population. Propofol, a widely used intravenous anesthetic, is associated with marked reductions in blood pressure due to vasodilation and attenuation of sympathetic activity (1,2). In contrast, etomidate is often favoured for its ability to preserve cardiovascular stability by minimizing adverse effects on myocardial contractility and vascular receptors (3,4).

For patients with cardiac comorbidities, fluctuations in blood pressure and heart rate during induction may precipitate myocardial ischemia, arrhythmias, or even hemodynamic collapse (5). Prior investigations have consistently shown that propofol administration can result in significant decreases in systolic blood pressure (SBP) and mean arterial pressure (MAP), frequently necessitating vasopressor support to maintain stability (6,7). Etomidate, while demonstrating superior control over SBP and MAP, has been limited in clinical use due to concerns regarding adrenal suppression (8,9). The comparative hemodynamic implications of these agents in cardiac patients undergoing non cardiac procedures remain a subject of ongoing debate.

This retrospective study was designed to evaluate the hemodynamic changes associated with etomidate versus propofol induction in patients with cardiac disease undergoing non cardiac surgery. Key parameters analysed included systolic and diastolic blood pressure (SBP, DBP), heart rate (HR), and cardiac output (CO), measured at baseline and following induction. The findings aim to provide clinically relevant insights into the optimal choice of anesthetic induction agent for patients with cardiovascular risk, thereby guiding perioperative management strategies.

This investigation was conducted as a retrospective observational study within a tertiary care hospital setting, following approval from the institutional ethics committee. Patient records were reviewed, and data from 150 adult individuals with documented cardiovascular disease who underwent non cardiac surgical procedures were included. Patient Selection: Eligible patients were between 40 and 80 years of age, classified as ASA (American Society of Anesthesiologists) physical status II or III, and had cardiac comorbidities such as hypertension, ischemic heart disease, or heart failure. Patients with known adrenal insufficiency, severe valvular disease, pregnancy, or documented drug allergy to the study medications were excluded. Study Groups: Based on anesthesia records, patients were categorized into two groups according to the induction agent administered: • Group P (Propofol): Received intravenous propofol at a dose of 2 mg/kg over 30 seconds. • Group E (Etomidate): Received intravenous etomidate at a dose of 0.3 mg/kg over 30 seconds. Anesthetic Technique: All patients had undergone standard preoperative evaluation and intraoperative monitoring, including electrocardiography, non invasive blood pressure measurement, and pulse oximetry. Preoxygenation with 100% oxygen for three minutes was routinely performed prior to induction. Following induction, fentanyl and rocuronium were administered to facilitate tracheal intubation. Maintenance of anesthesia was achieved with sevoflurane in a 50% oxygen air mixture, supplemented with intermittent fentanyl boluses. Hemodynamic Measurements: Hemodynamic parameters—systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), and cardiac output (CO)—were extracted from anesthesia charts at the following time points: • Baseline (pre induction) • Immediately after induction • 1 minute post induction • 3 minutes post induction • 5 minutes post induction Interventions: Any reduction in MAP greater than 20% from baseline was managed with intravenous fluids and vasopressor therapy, as documented in patient records. Statistical Analysis: Data were compiled and analysed using SPSS version 25 (IBM Corp., Armonk, NY). A p value < 0.05 was considered statistically significant.

A total of 150 patient records were retrospectively analysed, with individuals categorized into two groups based on the anesthetic induction agent received: etomidate (Group E) and propofol (Group P). Baseline demographic and clinical characteristics were statistically comparable between the two groups (p > 0.05), as detailed in Table 1.

No significant differences were observed in age distribution, gender ratio, body mass index (BMI), or prevalence of hypertension and diabetes mellitus across the cohorts. Pre-induction hemodynamic parameters—including systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR)—were also similar between the etomidate and propofol groups, indicating a balanced baseline profile prior to anesthesia administration.

Table 1: Demographic and Baseline Characteristics

Analysis of anesthesia records from 150 patients revealed distinct hemodynamic trends between those induced with propofol and those with etomidate. Immediately following induction, patients in the propofol group exhibited a marked reduction in systolic blood pressure (SBP), averaging 110 ± 7 mmHg, compared to 125 ± 8 mmHg in the etomidate group (p < 0.001). This hypotensive effect persisted, with SBP declining further to 98 ± 4 mmHg at five minutes post-induction in the propofol group, whereas SBP remained relatively stable in the etomidate group at 120 ± 5 mmHg (p < 0.001) (Table 2).

Heart rate (HR) measurements also differed significantly between groups. Patients receiving propofol showed a notable increase in HR from a baseline of 74 ± 6 bpm to 94 ± 6 bpm post-induction (p < 0.001). In contrast, the etomidate group maintained near-baseline HR values (75 ± 7 bpm vs. 79 ± 6 bpm; p = 0.12), indicating minimal chronotropic impact (Table 2).

Table 2: Hemodynamic Parameters at Different Time Points

Incidence of hypotension (defined as SBP < 90 mmHg) was significantly higher in the propofol group (30%) compared to the etomidate group (4%) (p < 0.001). Tachycardia occurred in 36% of propofol-treated patients versus 6% in the etomidate cohort (p < 0.001). Vasopressor support was required in 40% of propofol cases, while only 10% of etomidate patients needed such intervention (p < 0.001). Rates of bradycardia were comparable between the two groups, with no statistically significant difference (p = 0.52) (Table 3).

Table 3: Incidence of Hemodynamic Instability

In this retrospective analysis of 150 patients with pre-existing cardiac disease undergoing non-cardiac surgical procedures, the choice of anesthetic induction agent emerged as a critical determinant of intraoperative hemodynamic stability. The comparison between etomidate and propofol revealed that etomidate was associated with more favourable outcomes, particularly in terms of reduced episodes of hypotension and tachycardia.

Propofol, a widely used induction agent, is known to cause vasodilation and a subsequent reduction in systemic vascular resistance, often leading to clinically significant hypotension (1,2). In our cohort, patients receiving propofol demonstrated marked decreases in both systolic blood pressure (SBP) and mean arterial pressure (MAP) following induction. Previous literature has consistently reported blood pressure reductions of 20–30% from baseline values (3,4). The mechanism underlying this response involves suppression of sympathetic activity and inhibition of baroreceptor reflexes, thereby diminishing compensatory hemodynamic responses (5,6).

Conversely, patients induced with etomidate exhibited stable hemodynamic profiles. Etomidate exerted minimal influence on myocardial contractility and systemic vascular resistance, thereby maintaining MAP and SBP within acceptable ranges (7,8). Heart rate stability was also observed in the etomidate group, consistent with its lack of autonomic nervous system interference, which prevented the reflex tachycardia commonly seen with propofol-induced hypotension (9).

Our findings reaffirm the established risk of propofol-related tachycardia, likely mediated by baroreceptor-driven sympathetic activation in response to hypotension (10). This compensatory tachycardia increases myocardial oxygen demand, posing significant risks for patients with coronary artery disease (11). In contrast, etomidate did not precipitate tachycardic responses, underscoring its relative safety in maintaining cardiac stability (12).

A recognized limitation of etomidate is its transient suppression of cortisol synthesis via inhibition of 11-beta-hydroxylase (13). While single-dose induction has been linked to temporary adrenal insufficiency, these effects were not clinically significant in our patient population undergoing elective, short-duration procedures. Thus, the risk-benefit profile of etomidate remains favourable in this context (14,15).

The need for vasopressor support further distinguished the two groups. In our study, 40% of patients receiving propofol required pharmacologic blood pressure support, compared to only 10% in the etomidate group. This observation aligns with prior reports attributing higher vasopressor requirements to propofol-induced vasodilation (16,17). Consequently, propofol administration in vulnerable cardiac patients necessitates vigilant monitoring and proactive corrective measures such as fluid resuscitation or vasopressor therapy (18).

Overall, this retrospective study of 150 patients demonstrates that etomidate provides superior hemodynamic stability compared to propofol during induction in cardiac-compromised individuals undergoing non-cardiac surgery. The choice of induction agent should be individualized, taking into account patient comorbidities, surgical requirements, and institutional practices(19,20). Future research should extend beyond intraoperative outcomes to evaluate long-term postoperative cardiac events and recovery trajectories in patients managed with etomidate versus propofol induction(21).

Our study confirms that first-time complete denture wearers experience significant adaptation challenges, particularly in the initial weeks. However, comfort levels improve over time, and most patients achieve satisfactory adaptation within six months. Pain, chewing difficulties, and speech issues are common early complaints, but regular follow-ups and patient education can enhance the adaptation process. These findings emphasize the need for comprehensive patient support to improve the overall experience of denture wearers. Financial support and sponsorship No funding sources. Conflicts of interest There are no conflicts of interest

1.      Amarasena J, Jayasinghe V, Amarasena N, Yamada Y. Oral stereognostic ability during adaptation to new dentures in experienced and non-experienced complete denture wearers. Journal of Oral Biosciences. 2010 Jan 1;52(2):181-6.

2.      Čelebić A, Knezović-Zlatarić D, Papić M, Carek V, Baučić I, Stipetić J. Factors related to patient satisfaction with complete denture therapy. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2003 Oct 1;58(10):M948-53.

3.      Fujita H, Sano K, Sasaki S, Ohno-Matsui K, Tanaka T, Baba T, Mochizuki M. Ocular discomfort at the initial wearing of rigid gas permeable contact lenses. Japanese journal of ophthalmology. 2004 Jul;48:376-9.

4.      Hobrink J, Zarb GA, Bolender CL, Eckert S, Jacob R, Fenton A, Mericske-Stern R. Prosthodontic treatment for edentulous patients: complete dentures and implant-supported prostheses. Elsevier Health Sciences; 2003 Sep 17.

5.      Shigli K, Hebbal M, Angadi GS. Self‐reported assessment of intraoral prostheses among patients attending the prosthodontic department in a dental institute in India. Geriatrics & gerontology international. 2008 Jun;8(2):101-8.

6.      Aarts JM, Payne AG, Thomson WM. Patients' evaluation of two occlusal schemes for implant overdentures. Clinical implant dentistry and related research. 2008 Sep;10(3):140-56.

7.      Strassburger C, Kerschbaum T, Heydecke G. Influence of implant and conventional prostheses on satisfaction and quality of life: A literature review. Part 2: Qualitative analysis and evaluation of the studies. International Journal of Prosthodontics. 2006 Jul 1;19(4).

8.      Narain U, Garg R. Sameer & P. Narain: A Prospective Study Of The Quality Of Removable Prostheses And Patients’ Satisfaction In Post-Prosthetic Phase. The Internet Journal of Dental Science. 2010;9(1).

9.      Akeel RF. Effect of the quality of removable prostheses on patient satisfaction. J Contemp Dent Pract. 2009 Nov 1;10(6):E057-64.

10.   Rahn AO, Ivanhoe JR, Plummer KD. Textbook of complete dentures. PMPH-USA; 2009.

11.   Zarb G, White SN, Creugers NH, Müller F, MacEntee MI. Prosthodontics, endodontics, and other restorative care for frail elders. Oral Healthcare and the Frail Elder: A Clinical Perspective. 2010 Oct 28:211-35.

12.   Reddy LP, Sangur R. Comparison of manual and physiologically molded denture bases in complete denture wearers. Indian Journal of Dental Research. 2010 Oct 1;21(4):496-9.

13.   Shigli K. Aftercare of the complete denture patient. Journal of Prosthodontics: Implant, Esthetic and Reconstructive Dentistry. 2009 Dec;18(8):688-93.

14.   Petričević N, Rener-Sitar K. Oral health related quality of life in patients with new conventional complete dentures. Acta stomatologica Croatica: International journal of oral sciences and dental medicine. 2009 Dec 15;43(4):279-89.

15.   Carr AB, Brown DT. McCracken's removable partial prosthodontics-e-book. Elsevier Health Sciences; 2010 Jun 22.

16.   Trulsson U, Engstrand P, Berggren U, Nannmark U, Brånemark PI. Edentulousness and oral rehabilitation: experiences from the patients' perspective. European journal of oral sciences. 2002 Dec;110(6):417-24.

17.   Eitner S, Wichmann M, Schlegel A, Holst S. Clinical study on the correlation between psychogenic dental prosthesis incompatibility, oral stereognosis, and the psychologic diagnostic tools SCL-90-R and CES-D. International Journal of Prosthodontics. 2007 Sep 1;20(5).

18.   Müller F, Schädler M, Wahlmann U, Newton JP. The use of implant-supported prostheses in the functional and psychosocial rehabilitation of tumor patients. International Journal of Prosthodontics. 2004 Sep 1;17(5).

19.   Kawai Y, Murakami H, Takanashi Y, Lund JP, Feine JS. Efficient resource use in simplified complete denture fabrication. Journal of Prosthodontics: Implant, Esthetic and Reconstructive Dentistry. 2010 Oct;19(7):512-6.

20.   Levin B, Richardson GD. Complete denture prosthodontics. A manual for clinical procedures. 2002:54-.

21.   Jang KS, Kim YS. Comparison of oral sensory function in complete denture and implant‐supported prosthesis wearers. Journal of oral rehabilitation. 2001 Mar;28(3):220-5.

Greenland K, Margrain TH. Evaluating the association between anxiety and satisfaction. Optometry and Vision Science. 2009 Mar 1;86(3):216-21.