冠状动脉支架置入术后患者行高风险手术时术中低血压与术后心肌损伤的关系：回顾性研究
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冠状动脉支架置入术后患者行高风险手术时术中低血压与术后心肌损伤的关系：回顾性研究
翻译：牛振瑛 编辑：冯玉蓉 审校：曹莹
背景：我们进行了一项单中心回顾性研究，评估术中低血压(IOH)对术前心肌肌钙蛋白I水平正常的冠状动脉支架置入患者行大型非心脏手术后心肌损伤的影响。虽然IOH被认为会增加既往冠状动脉支架置入者术后心肌损伤的风险，但凶险性低血压的水平和持续时间尚未阐明。
方法：在2010年1月至2017年3月期间接受非心脏手术的2517例既往冠状动脉支架置入患者中，我们分析了195例接受大型手术(血管、腹部和胸部手术)的患者，这些患者术前高敏感性心肌肌钙蛋白I（hs-cTnI）水平正常，术后3天内随访。术后心肌损伤定义为hs-cTnI水平大于第99百分位参考值。首次IOH定义为较诱导前平均血压下降≥50%、40%或30%。IOH附加定义是绝对平均血压<70mmHg、<60mmHg或<50 mmHg。用多因素Logistic回归分析模拟低血压与心肌损伤的关系。
结果：53例患者发生了心肌损伤(27.2%)。预先确定的IOH水平与术后心肌损伤无明显相关性，但心肌损伤患者术中持续使用正性肌力药/血管升压药明显增多(P=0.004)。手术时间≥166min(OR=2.823，95%CI 1.184~6.731，P=0.019)和腹部血管手术(OR=2.693，95%CI 1.213~5.976，P=0.015)是心肌损伤的独立危险因素。
结论：虽然既往有冠脉支架置入且hs-cTnI水平正常的患者，未显示不同程度的IOH与非心脏手术后心肌损伤存在相关性，但术后心肌损伤患者术中对正性肌力药/血管升压药的需求较高。腹部血管手术和手术时间是术后心肌损伤的独立危险因素。
原始文献来源：Lee SH, Kim JA, Heo BY, et al.Association between intraoperative hypotension and postoperative myocardial injury in patients with prior coronary stents undergoing high‑risk surgery: a retrospective study[J].Journal of Anesthesia.DOI: 10.1007/s00540-020-02736-4
Association between intraoperative hypotension and postoperative myocardial injury in patients with prior coronary stents undergoing high‑risk surgery: a retrospective study
Abstract
Purpose We conducted a single-center retrospective study to evaluate the effects of intraoperative hypotension (IOH) on postoperative myocardial injury during major noncardiac surgery in patients with prior coronary stents with preoperatively normal cardiac troponin I levels. Although IOH is assumed to increase the risk of postoperative myocardial injury in patients with prior coronary stents, the level and duration of hazardous low blood pressure have not been clarified.
Methods Of 2517 patients with prior coronary stents undergoing noncardiac surgery between January 2010 and March 2017, we analyzed 195 undergoing major surgery (vascular, abdominal, and thoracic surgery) who had a normal preoperative high-sensitivity cardiac troponin I (hs-cTnI) level and were followed up postoperatively within 3 days. Postoperative myocardial injury was defined as a hs-cTnI level greater than the 99th percentile reference value. Primary IOH exposure was defined as a decrease of ≥ 50%, 40%, or 30% from the preinduction mean blood pressure. Additional definition of IOH was absolute mean blood pressure < 70, < 60 or < 50 mmHg. Multivariate logistic regression was used to model the exposure and myocardial injury.
Results Myocardial injury occurred in 53 (27.2%) cases. The predefined levels of IOH were not significantly associated with postoperative myocardial injury, but intraoperative continuous inotropes/vasopressors use was significantly higher in patients with myocardial injury (P = 0.004). Operation time ≥ 166 min (OR = 2.823, 95% CI 1.184–6.731, P = 0.019) and abdominal vascular surgery (OR = 2.693, 95% CI 1.213–5.976, P = 0.015) were independent risk factors for myocardial injury.
Conclusion Although patients with prior coronary stents with normal hs-cTnI levels did not show association between varying levels of IOH and postoperative myocardial injury after noncardiac surgery, intraoperative need of continuous inotropes/vasopressors was higher in patients with postoperative myocardial injury. Abdominal vascular surgery and surgical time were independent risk factors for myocardial injury after surgery.
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