冠状动脉疾病非心脏外科手术患者围术期低血压与心血管事件的关系
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Relationship between Perioperative Hypotension and Perioperative Cardiovascular Events in Patients with Coronary Artery Disease Undergoing Major Noncardiac Surgery
背景与目的
非心脏手术患者围术期低血压与心血管事件相关。目前尚不清楚冠状动脉疾病的严重程度是否决定了围术期低血压对心血管事件发生风险的敏感性。
方 法
本试验为对一项国际前瞻性盲法队列研究的子研究的回顾性探索性分析，共纳入955名45岁或45岁以上有冠状动脉疾病病史或危险因素的患者，择期住院非心脏手术患者术前前接受冠状动脉断层血管造影确定冠状动脉疾病的严重程度。本研究探讨了冠状动脉疾病的严重程度与围术期低血压（定义为手术期间或手术后任何时间段收缩压小于90 mmHg，持续10分钟或更长时间，并开始干预）对患者术后30天内心肌梗死或心心血管事件的潜在相互作用。血管造影人员对研究不知情；患者、临床医生和结果评估人员对血管造影结果均不知情。
结 果
术后30天内心血管事件（心肌梗死或心血管疾病）发生率为7.7%（74/955），包括2.7%（8/293）无阻塞性冠状动脉疾病或低血压，而6.7%（21/314）阻塞性冠状动脉疾病但无低血压（HR:2.51；95%CI:1.11-5.66；P=0.027）;低血压但无阻塞性冠状动脉疾病的患者为8.8%（14/159）（HR：3.85；95%CI，1.62-9.19；P=0.002）;低血压合并梗阻性冠状动脉疾病的患者为16.4%（31/189）（HR:7.34；95%CI：3.37-15.96；P<0.001）；低血压与心血管事件独立相关（HR:3.17；95%CI:1.99-5.06；P<0.001）,这一相关性在无阻塞性冠状动脉疾病的患者中仍存在，但与不同程度冠状动脉疾病没有显著差异（相互作用P值，0.599）。
结 论
心脏手术患者围手术期低血压与心血管事件发生存在相关性，但其与术前计算机断层扫描血管造影术所诊断的冠状动脉疾病程度无关。
原始文献摘要
Pavel S. Roshanov,M.Sc., Tej Sheth,Emmanuelle Duceppe；Relationship between Perioperative Hypotension and Perioperative Cardiovascular Events in Patients with Coronary Artery Disease Undergoing Major Noncardiac Surgery；Anesthesiology 2019; 130:00–00
Background: Perioperative hypotension is associated with cardiovascular events in patients having noncardiac surgery. It is unknown if the severity of preexisting coronary artery disease determines susceptibility to the cardiovascular risks of perioperative hypotension.
Methods: In this retrospective exploratory analysis of a substudy of an international prospective blinded cohort study, 955 patients 45 yr of age or older with history or risk factors for coronary artery disease underwent coronary computed tomographic angiography before elective inpatient noncardiac surgery. The authors evaluated the potential interaction between angiographic findings and perioperative hypotension (defined as systolic blood pressure less than 90 mmHg for a total of 10 min or more during surgery or for any duration after surgery and for which intervention was initiated) on the composite outcome of time to myocardial infarction or cardiovascular death up to 30 days after surgery. Angiography assessors were blinded to study outcomes; patients, treating clinicians, and outcome assessors were blinded to angiography findings.
Results: Cardiovascular events (myocardial infarction or cardiovascular death within 30 days after surgery) occurred in 7.7% of patients (74/955), including in 2.7% (8/293) without obstructive coronary disease or hypotension compared to 6.7% (21/314) with obstructive coronary disease but no hypotension (hazard ratio, 2.51; 95% CI, 1.11 to 5.66; P = 0.027), 8.8% (14/159) in patients with hypotension but without obstructive coronary disease (hazard ratio, 3.85; 95% CI, 1.62 to 9.19; P = 0.002), and 16.4%(31/189) with obstructive coronary disease and hypotension (hazard ratio, 7.34; 95% CI, 3.37 to 15.96; P < 0.001). Hypotension was independently associated with cardiovascular events (hazard ratio, 3.17; 95% CI, 1.99 to 5.06; P < 0.001). This association remained in patients without obstructive disease and did not differ significantly across degrees of coronary disease (P value for interaction, 0.599).
Conclusions: In patients having noncardiac surgery, perioperative hypotension was associated with cardiovascular events regardless of the degree of coronary artery disease on preoperative coronary computed tomographic angiography.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：王贵龙 编辑：李华宇 审校：王贵龙