Amar David, Goenka Anuj, Zhang Hao, Park Bernard, Thaler Howard T
Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
Ann Thorac Surg. 2006 Sep;82(3):1057-61. doi: 10.1016/j.athoracsur.2006.03.103.
In older patients who are known to be at greater risk for atrial fibrillation, we aimed to determine whether patients who develop atrial fibrillation-flutter (AF) after major thoracic surgery have an exaggerated white blood cell (WBC) count in response to surgical stress compared with those who do not develop AF.
Using a prospective database, 272 patients 60 years or older who were in sinus rhythm before surgery and had elective lobectomy, pneumonectomy, or esophagectomy were studied. Patients did not receive perioperative medications to prevent AF. Clinical characteristics and preoperative 12-lead electrocardiogram were examined and WBC counts were recorded for patients prior to and for up to five days after surgery.
Atrial fibrillation-flutter was observed in 74 of 272 (27%) patients a median of 3 days after surgery. The increase in WBC count from preoperative to postoperative day 1 and age were jointly significant predictors of AF by multiple logistic regression (area under the receiver operating characteristic curve = 0.69). Using this model, a twofold increase in WBC from presurgery to postoperative day 1 corresponded to a 3.3-fold increase in the odds of developing AF (95% confidence interval [CI] 2.0 to 8.3) and for each 10 year increase in age, a 1.8-fold increase in risk of AF (95% CI 1.1 to 2.8) was seen.
Increments in WBC were greater in patients with AF and coincided with the peak onset of AF. These prospective data support an important role for stress-mediated autonomic mechanisms in the pathogenesis of AF after major thoracic surgery. We aim to examine further whether WBC elevations on postoperative day one can help further risk stratify patients younger than 60 years or those with the highest risk who could benefit from one or more AF prevention strategies.
在已知发生心房颤动风险较高的老年患者中，我们旨在确定与未发生心房颤动的患者相比，接受胸科大手术后发生心房颤动-扑动（AF）的患者在应对手术应激时白细胞（WBC）计数是否会过度升高。
利用前瞻性数据库，对272例60岁及以上、术前为窦性心律且接受择期肺叶切除术、全肺切除术或食管切除术的患者进行研究。患者未接受预防房颤的围手术期药物治疗。检查临床特征和术前12导联心电图，并记录患者术前及术后长达五天的白细胞计数。
272例患者中有74例（27%）在术后中位3天观察到心房颤动-扑动。通过多因素逻辑回归分析，术前至术后第1天白细胞计数的增加和年龄是房颤的共同显著预测因素（受试者工作特征曲线下面积=0.69）。使用该模型，术前至术后第1天白细胞增加两倍对应发生房颤的几率增加3.3倍（95%置信区间[CI]2.0至8.3），并且年龄每增加10岁，房颤风险增加1.8倍（95%CI 1.1至2.8）。
房颤患者的白细胞增加幅度更大，且与房颤的发病高峰时间一致。这些前瞻性数据支持应激介导的自主神经机制在胸科大手术后房颤发病机制中起重要作用。我们旨在进一步研究术后第1天白细胞升高是否有助于对60岁以下患者或可能从一种或多种房颤预防策略中获益的最高风险患者进行进一步的风险分层。
