血管加压素联合儿茶酚胺与单独应用儿茶酚胺治疗分配性休克患者房颤发生率的比较：系统回顾及META-分析
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Association of Vasopressin Plus Catecholamine Vasopressors vs Catecholamines Alone With Atrial Fibrillation in Patients With Distributive Shock A Systematic Review and Meta-analysis
背景与目的
分布性休克，是由于血管扩张过度引起的，最常见于严重的感染，抗利尿激素是一种可替代儿茶酚胺的抗利尿药。非儿茶酚胺类血管加压素支持的血压可以减少肾上腺素能受体的刺激，减少心肌的氧气需求。心房颤动在使用儿茶酚胺时很常见，与不良事件有关，包括死亡率和住院时间延长(LOS)。为了确定使用血管加压素+儿茶酚胺加压治疗与仅用儿茶酚胺血管加压治疗相比是否与不良事件风险减少相关。
方 法
在对包括3088名分布性休克患者的23项试验的系统综述和荟萃分析中，与儿茶酚胺血管加压药单独相比，加用加压素使儿茶酚胺血管加压药与房颤风险降低显着相关。在MEDLINE，EMBASE和CENTRAL从开始到2018年2月进行了检索。询问专家并且搜索meta-registries以确定正在进行的试验。
结 果
我们确定了23个随机临床试验(3088例;平均年龄61.1岁;女性,45.3%)。高质量的证据支持与血管加压素治疗相关的房颤风险较低(RR, 0.77 [95% CI, 0.67 - 0.88];风险的区别(RD)−0.06(95% CI,0.13−0.01])。对于死亡率，总的RR估计为0.89 ;然而，当局限于低偏倚风险的试验时，RR估计值为0.96(95%可信区间，0.84到1.11)。RRT的估计值为0.74(95%可信区间0.51 - 1.08)。然而，在一项低风险试验为限的分析中，RR为0.70 (95% CI, 0.53至0.92,)。对于其他结果，合并的风险没有显著差异。
结 论
在这项系统综述和荟萃分析中，儿茶酚胺联合血管加压素与单独应用儿茶酚胺相比，房颤风险较低。次要结果的发现各不相同。
原始文献摘要
Mcintyre W F, Um K J, Alhazzani W, et al. Association of Vasopressin Plus Catecholamine Vasopressors vs Catecholamines Alone With Atrial Fibrillation in Patients With Distributive Shock: A Systematic Review and Meta-analysis[J]. Jama the Journal of the American Medical Association, 2018, 319(18):1889.
Abstract:
Importance Vasopressin is an alternative to catecholamine vasopressors for patients with distributive shock—a condition due to excessive vasodilation, most frequently from severe infection. Blood pressure support with a noncatecholamine vasopressor may reduce stimulation of adrenergic receptors and decrease myocardial oxygen demand. Atrial fibrillation is common with catecholamines and is associated with adverse events, including mortality and increased length of stay (LOS).
Objectives To determine whether treatment with vasopressin + catecholamine vasopressors compared with catecholamine vasopressors alone was associated with reductions in the risk of adverse events.
Data Sources MEDLINE, EMBASE, and CENTRAL were searched from inception to February 2018. Experts were asked and meta-registries searched to identify ongoing trials.
Study Selection Pairs of reviewers identified randomized clinical trials comparing vasopressin in combination with catecholamine vasopressors to catecholamines alone for patients with distributive shock.
Data Extraction and Synthesis Two reviewers abstracted data independently. A random-effects model was used to combine data.
Main Outcomes and Measures The primary outcome was atrial fibrillation. Other outcomes included mortality, requirement for renal replacement therapy (RRT), myocardial injury, ventricular arrhythmia, stroke, and LOS in the intensive care unit and hospital. Measures of association are reported as risk ratios (RRs) for clinical outcomes and mean differences for LOS.
Results Twenty-three randomized clinical trials were identified (3088 patients; mean age, 61.1 years [14.2]; women, 45.3%). High-quality evidence supported a lower risk of atrial fibrillation associated with vasopressin treatment (RR, 0.77 [95% CI, 0.67 to 0.88]; risk difference [RD], −0.06 [95% CI, −0.13 to 0.01]). For mortality, the overall RR estimate was 0.89 (95% CI, 0.82 to 0.97; RD, −0.04 [95% CI, −0.07 to 0.00]); however, when limited to trials at low risk of bias, the RR estimate was 0.96 (95% CI, 0.84 to 1.11). The overall RR estimate for RRT was 0.74 (95% CI, 0.51 to 1.08; RD, −0.07 [95% CI, −0.12 to −0.01]). However, in an analysis limited to trials at low risk of bias, RR was 0.70 (95% CI, 0.53 to 0.92, P for interaction = .77). There were no significant differences in the pooled risks for other outcomes.
Conclusions and Relevance In this systematic review and meta-analysis, the addition of vasopressin to catecholamine vasopressors compared with catecholamines alone was associated with a lower risk of atrial fibrillation. Findings for secondary outcomes varied.
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