择期非心脏手术的术前血压和术后30天死亡风险的队列研究
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Cohort study of preoperative blood pressure and
risk of 30-day mortality after elective non-cardiac surgery
背景与目的
术前血压（BP）阈值与术后死亡率升高的相关性尚不清楚。本研究探讨了择期非心脏手术的术前BP与术后30天死亡率之间的关系。
方 法
根据英国临床实践研究数据库（2004-2013）的初级治疗数据进行了一项队列研究。通过简单和完全调整的多变量逻辑回归模型，包括了与30天死亡率相关的收缩压和舒张压值的限制三次样条函数。完整的模型包括29例围手术期危险因素，如年龄、性别、合并症、药物和手术风险量表等。对年龄（> 65岁vs ＜65岁）和测量BP的时间进行敏感性分析。
结 果
共纳入251，567名成年患者，手术后30天内有589名患者（0.23％）死亡。在校正所有风险因素后，术前低血压与术后死亡率的优势比（OR）在统计学上的显着性增加有关。与标准值（120/80mmHg）相比，术前收缩压为119mmHg（校正后的OR 1.02 [95％置信区间（CI）1.01-1.02]）和舒张压为63mmHg [OR 1.24（95％CI 1.03-1.49）]的风险阈值具有统计学意义。随着血压下降，死亡风险升高。亚组分析表明，与低血压相关的风险仅限于老年人。校正后的分析发现，舒张压增高与整个队列中术后死亡率升高有关。
结 论
在这项大样本的观察性研究中，我们发现老年人术前BP低与术后死亡率升高有显着的剂量依赖性的关系。在整个群体中，舒张压升高而非收缩压，与死亡率增加有关。
原始文献摘要
S. Venkatesan ,P. R. Myles ,H. J. Manning,et.al, Cohort study of preoperative blood pressure and risk of 30-day mortality after elective non-cardiac surgery.Br J Anaesth aex056.15 June 2017.
Background: Preoperative blood pressure (BP) thresholds associated with increased postoperative mortality remain unclear. We investigated the relationship between preoperative BP and 30-day mortality after elective non-cardiac surgery.
Methods: We performed a cohort study of primary care data from the UK Clinical Practice Research Datalink (2004–13). Parsimonious and fully adjusted multivariable logistic regression models, including restricted cubic splines for numerical systolic and diastolic BP, for 30-day mortality were constructed. The full model included 29 perioperative risk factors, including age, sex, comorbidities, medications, and surgical risk scale. Sensitivity analyses were conducted for age (>65 vs <65 years old) and the timing of BP measurement.
Results: A total of 251 567 adults were included, with 589 (0.23%) deaths within 30 days of surgery. After adjustment for all risk factors, preoperative low BP was consistently associated with statistically significant increases in the odds ratio (OR) of postoperative mortality. Statistically significant risk thresholds started at a preoperative systolic pressure of 119 mm Hg (adjusted OR 1.02 [95% confidence interval (CI) 1.01–1.02]) compared with the reference (120 mm Hg) and diastolic pressure of 63 mm Hg [OR 1.24 (95% CI 1.03–1.49)] compared with the reference (80 mm Hg). As BP decreased, the OR of mortality risk increased. Subgroup analysis demonstrated that the risk associated with low BP was confined to the elderly. Adjusted analyses identified that diastolic hypertension was associated with increased postoperative mortality in the whole cohort.
Conclusions: In this large observational study we identified a significant dose-dependent association between low preoperative BP values and increased postoperative mortality in the elderly. In the whole population, elevated diastolic, not systolic, BP was associated with increased mortality.
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