D'Alessandro Cosimo, Leprince Pascal, Golmard Jean Louis, Ouattara Alexandre, Aubert Stéphane, Pavie Alain, Gandjbakhch Iradj, Bonnet Nicolas
Institute of Cardiology, Division of Thoracic and Cardiovascular Surgery, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie-Paris, Paris, France.
J Thorac Cardiovasc Surg. 2007 Jul;134(1):29-37. doi: 10.1016/j.jtcvs.2007.02.028.
We sought to evaluate the effect of a strict glycemic control protocol on a series of diabetic patients undergoing surgical myocardial revascularization.
Between January 2003 and June 2004, 300 diabetic patients undergoing myocardial revascularization received a local protocol of insulin administration (protocol, group P). Patients were divided into 2 risk classes, according to their additive EuroSCORE value: low-moderate risk (0-4) and moderate-high risk (>4). The logistic EuroSCORE algorithm was used to calculate the expected probability of death. A control group was selected, including a series of 300 consecutive diabetic patients (no protocol group, group NP) who underwent coronary artery bypass grafting between March 2001 and September 2002, just before the introduction of the protocol. A propensity analysis was performed to control for selection bias.
Both groups showed similar EuroSCORE risk profiles: mean additive and logistic EuroSCORE values were 4.16 and 4.29 in group P versus 3.93 and 3.91 in group NP. Observed and expected mortalities of group P were 0.6% versus 1.8% (low-moderate risk), 2.5% versus 8.0% (moderate-high risk, P = .03), and 1.3% versus 4.3% (entire group, P = .01). Observed and expected mortalities of group NP were 1.6% versus 1.9% (low-moderate risk), 8.3% versus 7.5% (moderate-high risk), and 4.0% versus 3.9% (entire group). Logistic regression confirmed observed mortality in group P to be significantly lower than the expected logistic EuroSCORE mortality. After risk adjustment, the protocol allowed us to reduce the mortality odds by 72% (odds ratio, 0.282; 95% confidence interval, 0.092-0.859; P < .03). Subgroup analysis for moderate- to high-risk patients showed the protocol to improve mortality (odds ratio, 0.24; P < .05), whereas no significant improvement was found in low- to moderate-risk patients. Addition of the propensity score to the multivariable analysis did not significantly displace P values and odds ratios. Sensitivity analysis of patients who underwent coronary artery bypass grafting without additional procedures showed the protocol to maintain its protective effect (odds ratio, 0.15; P < .05).
Optimal glucose control highly reduces EuroSCORE expected mortality in diabetic patients undergoing myocardial revascularization, especially in moderate- to high-risk patients.
我们旨在评估严格血糖控制方案对一系列接受外科心肌血运重建术的糖尿病患者的影响。
在2003年1月至2004年6月期间，300例接受心肌血运重建术的糖尿病患者接受了局部胰岛素给药方案（方案组，P组）。根据欧洲心脏手术风险评估系统（EuroSCORE）相加值将患者分为2个风险等级：低 - 中度风险（0 - 4）和中度 - 高度风险（>4）。使用逻辑EuroSCORE算法计算预期死亡概率。选择一个对照组，包括2001年3月至2002年9月期间，即在该方案引入之前接受冠状动脉旁路移植术的300例连续糖尿病患者（无方案组，NP组）。进行倾向分析以控制选择偏倚。
两组显示出相似的EuroSCORE风险特征：P组的平均相加和逻辑EuroSCORE值分别为4.16和4.29，而NP组为3.93和3.91。P组的观察到的死亡率和预期死亡率分别为0.6%对1.8%（低 - 中度风险），2.5%对8.0%（中度 - 高度风险，P = 0.03），以及1.3%对4.3%（整个组，P = 0.01）。NP组的观察到的死亡率和预期死亡率分别为1.6%对1.9%（低 - 中度风险），8.3%对7.5%（中度 - 高度风险），以及4.0%对3.9%（整个组）。逻辑回归证实P组观察到的死亡率显著低于预期的逻辑EuroSCORE死亡率。经过风险调整后，该方案使我们能够将死亡几率降低72%（比值比，0.282；95%置信区间，0.092 - 0.859；P < 0.03）。对中度至高度风险患者的亚组分析显示该方案可改善死亡率（比值比，0.24；P < 0.05），而在低度至中度风险患者中未发现显著改善。将倾向得分添加到多变量分析中并未显著改变P值和比值比。对未进行额外手术的冠状动脉旁路移植术患者的敏感性分析显示该方案保持其保护作用（比值比，0.15；P < 0.05）。
最佳血糖控制可显著降低接受心肌血运重建术的糖尿病患者的EuroSCORE预期死亡率，尤其是在中度至高度风险患者中。
