The ENIGMA II Trial:Nitrous Oxide Anaesthesia and Cardiac Morbidity After Major Surgery: a Randomised Controlled Trial

Coronary Artery Disease Clinical Trial

Official title:

Large, Randomised, Parallel-group, Controlled Trial, With Patients Randomly Allocated to Either N2O-containing (70% N2O in Oxygen [FiO2 0.3]) or N2O-free (70% Nitrogen in Oxygen [FiO2 0.3]).

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT00430989
• Other study ID #: 6/07
• Status: Completed
• Phase: Phase 4
• Start date: April 2007
• Est. completion date: September 2013

Study information

• Verified date: March 2019
• Source: Bayside Health
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

To investigate the safety of nitrous oxide (N2O) anaesthesia in patients with risk factors for coronary artery disease undergoing major surgery.

Description:

Approximately 25% of patients undergoing major surgery have known coronary artery disease (CAD) or risk factors for CAD.

N2O interferes with vitamin B12 and folate metabolism. This impairs production of methionine (from homocysteine), used to form tetrahydrofolate and thymidine during DNA synthesis. It has been repeatedly demonstrated that N2O anaesthesia increases postoperative homocysteine levels. Chronic hyperhomocysteinaemia is associated with cardiovascular disease, and acute hyperhomocysteinaemia is known to cause endothelial dysfunction. One small trial has demonstrated an increased incidence of postoperative myocardial ischaemia in patients receiving N2O anaesthesia. Reducing postoperative myocardial infarction and death are important aims for those with CAD undergoing major surgery.

Our previous trial (ENIGMA) studied 2050 patients and identified some serious adverse effects, but most patients were not at risk of CAD and so we could not reliably assess serious cardiac complications. We propose a large simple randomized clinical trial of 7,000 patients to provide a definitive evaluation of the safety of N2O anaesthesia.

Updated statistical analysis plan can be found at www.enigma2.org.au.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 7112
• Est. completion date: September 2013
• Est. primary completion date: September 2013
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria

1. Adult males and females age = 45 years, undergoing noncardiac surgery and general anaesthesia expected to exceed two hours.

2. At increased risk of cardiac events, defined as any of

1. history of coronary artery disease as defined by a history of any one of the following: i. angina ii. MI iii. segmental wall motion abnormality on echocardiography or a fixed defect on radionuclide imaging iv. a positive exercise stress test for cardiac ischaemia v. a positive radionuclide exercise, echocardiographic exercise, or pharmacological cardiovascular stress test for cardiac ischaemia vi. coronary revascularization (CABG or PTCA) vii. angiographic evidence of atherosclerotic stenosis > 50% of the diameter of any coronary artery viii. ECG with pathological Q waves in two contiguous leads

2. heart failure

3. cerebrovascular disease thought due to atherothrombotic disease

4. aortic or peripheral vascular disease

5. or three or more of the following risk factors:

• age =70 years

• any history of congestive heart failure

• diabetes and currently on an oral hypoglycaemic agent or insulin therapy

• current treatment for hypertension

• preoperative serum creatinine >175 micro mol/L (> 2.0 mg/dl)

• current or previous high cholesterol =6.2 mmol/L (> 240 mg/dl)

• history of a transient ischemic attack (TIA) (i.e. a transient focal neurological deficit that lasted less than 24 hours and thought to be vascular in origin)

• emergency/urgent surgery (i.e. surgery which must be undertaken within 24 hours of acute presentation to hospital)

• high-risk type of surgery (i.e. intrathoracic or intraperitoneal)

Exclusion Criteria

1. having cardiac surgery

2. marked impairment of gas-exchange expected to require Fi02> 0.5 intraoperatively

3. specific circumstances where N2O is contraindicated (eg. volvulus, pulmonary hypertension, raised intracranial pressure) or the anaesthetist plans to use supplemental oxygen (eg. colorectal surgery)

4. N2O unavailable for use.

Related Conditions & MeSH terms

• Coronary Artery Disease
• Coronary Disease
• Myocardial Ischemia

Intervention

Other:
• Nitrous Oxide
General anaesthesia with the inclusion of Nitrous Oxide at 70%
• No Nitrous Oxide
General anaesthesia with no use of Nitrous Oxide

Locations

Country	Name	City	State
Australia	Alfred Hosptial	Melbourne	Victoria

Sponsors (2)

Lead Sponsor	Collaborator
Bayside Health	National Health and Medical Research Council, Australia

Country where clinical trial is conducted

Australia, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	The Primary Endpoint is a Composite of Death and Cardiovascular Events (Clinical and Silent MI, Cardiac Failure, Cardiac Arrest, Pulmonary Embolism, and Stroke) Measured at 30 Days After Surgery.		30 days post op
Secondary	Myocardial Infarction (MI)		30 days post op
Secondary	Cardiac Arrest		30 days
Secondary	Pulmonary Embolism		30 Days Post op
Secondary	Stroke		30 Days Post op
Secondary	Wound Infection		30 Days Post op
Secondary	Hospital Stay (Days)		30 Days Post Op

External Links

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