Posner K L, Van Norman G A, Chan V
Department of Anesthesiology, University of Washington, Seattle 98195-6540, USA.
Anesth Analg. 1999 Sep;89(3):553-60. doi: 10.1097/00000539-199909000-00003.
In this retrospective cohort study, we compared adverse cardiac outcomes after noncardiac surgery among patients with prior percutaneous transluminal coronary angioplasty (PTCA), patients with nonrevascularized coronary artery disease (CAD), and normal controls. Inpatient hospital discharge abstracts from all nonfederal acute care hospitals in Washington State linked to death certificates were evaluated. Patients > or =45 yr old with prior PTCA who underwent noncardiac surgery from 1987 to 1993 were matched by age, sex, surgery type, and discharge year to 686 patients with CAD and to 2155 normal controls (no CAD). We compared risk for adverse cardiac outcomes (death, myocardial infarction, angina, congestive heart failure, malignant dysrhythmia, cardiogenic shock, coronary artery bypass graft, or PTCA) within 30 days. Patients with PTCA had twice the risk of adverse cardiac outcome as normal controls (odds ratio [OR] 1.98; P < 0.001), with a higher risk of angina (OR 7.84), congestive heart failure (OR 2.06), and myocardial infarction (OR 3.86) but a lower risk of death (OR 0.46; P < 0.001). Patients with PTCA had half the risk of adverse cardiac outcome as patients with CAD (OR 0.50; P < 0.001), including less risk of angina (OR 0.51) and congestive heart failure (OR 0.40; P < 0.001), but no difference in myocardial infarction (P = 0.304) or death (P = 0.436). No difference was found between 142 patients with recent PTCA (< or =90 days before noncardiac surgery) matched to patients with CAD (OR 0.90; P = 0.396). Patients revascularized by PTCA >90 days before noncardiac surgery seem to have a lower risk of poor outcome than nonrevascularized patients, although not as low as normal controls. For recent PTCA patients, the lack of difference compared with CAD patient outcomes requires a larger sample size for verification. Present findings do not lend support to a role for prophylactic PTCA to improve noncardiac surgery outcomes. This investigation did not control for CAD severity, medical management, or comorbidities. Study of these factors is needed before the clinical implications of PTCA for noncardiac surgical risk can be completely assessed.
Hospital records showed patients with prior percutaneous transluminal coronary angioplasty were twice as likely as healthy patients to have an adverse cardiac outcome after noncardiac surgery, although their risk was reduced by half compared with patients with untreated coronary artery disease. Further study of the role of percutaneous transluminal coronary angioplasty in modulating noncardiac surgery risk is needed.
在这项回顾性队列研究中，我们比较了既往接受经皮腔内冠状动脉成形术（PTCA）的患者、未行血运重建的冠状动脉疾病（CAD）患者以及正常对照者在非心脏手术后的不良心脏结局。对华盛顿州所有与死亡证明相关联的非联邦急症护理医院的住院出院摘要进行了评估。将1987年至1993年间接受非心脏手术且年龄≥45岁的既往PTCA患者，按照年龄、性别、手术类型和出院年份与686例CAD患者及2155例正常对照者（无CAD）进行匹配。我们比较了30天内不良心脏结局（死亡、心肌梗死、心绞痛、充血性心力衰竭、恶性心律失常、心源性休克、冠状动脉旁路移植术或PTCA）的风险。PTCA患者发生不良心脏结局的风险是正常对照者的两倍（优势比[OR]1.98；P<0.001），心绞痛（OR 7.84）、充血性心力衰竭（OR 2.06）和心肌梗死（OR 3.86）的风险较高，但死亡风险较低（OR 0.46；P<0.001）。PTCA患者发生不良心脏结局的风险是CAD患者的一半（OR 0.50；P<0.001），包括心绞痛（OR 0.51）和充血性心力衰竭（OR 0.40；P<0.001）的风险较低，但心肌梗死（P = 0.304）或死亡（P = 0.436）无差异。在142例近期接受PTCA（非心脏手术前≤90天）的患者与CAD患者匹配组之间未发现差异（OR 0.90；P = 0.396）。非心脏手术前>90天接受PTCA血运重建的患者似乎比未行血运重建的患者不良结局风险更低，尽管不如正常对照者低。对于近期接受PTCA的患者，与CAD患者结局相比缺乏差异需要更大样本量进行验证。目前的研究结果不支持预防性PTCA在改善非心脏手术结局方面的作用。本研究未对CAD严重程度、药物治疗或合并症进行控制。在能够全面评估PTCA对非心脏手术风险的临床意义之前，需要对这些因素进行研究。
医院记录显示，既往接受经皮腔内冠状动脉成形术的患者在非心脏手术后发生不良心脏结局的可能性是健康患者的两倍，尽管与未治疗的冠状动脉疾病患者相比其风险降低了一半。需要进一步研究经皮腔内冠状动脉成形术在调节非心脏手术风险中的作用。
