Department of Anesthesiology, Beijing Chaoyang Hospital, Beijing, China.
J Cardiothorac Vasc Anesth. 2011 Apr;25(2):288-98. doi: 10.1053/j.jvca.2010.09.021. Epub 2010 Dec 13.
The influence of diabetes mellitus (DM) on mortality and morbidity in patients undergoing coronary artery bypass graft (CABG) surgery has remained uncertain due to conflicting conclusions from clinical trials measuring the association between diabetes and perioperative risk. Therefore, a quantitative meta-analysis was undertaken to evaluate the available evidence from prospective and historic cohort clinical trials. The purpose of this study was to determine the significance and magnitude of impact of DM on mortality, morbidity and resource-related outcomes for patients undergoing CABG over the past few decades and in the contemporary setting.
MEDILINE, EMBase, BIOSIS Preview, CBMDisc, CNKI and WanFang databases were searched, supplemented by hand search, without language limitations, for studies published from January 1981 to October 2008. Data extraction included study design, setting, inclusion/exclusion criteria, population characteristics, statistical method, length of follow-up and clinical outcomes. Eligible studies were assessed for quality.
Of the 132 identified studies, 24 cohort studies with a median follow-up of 4.3 years were selected for analysis. A total of 100,217 patients (28,168 with DM and 72,049 without DM), were included in the meta-analysis. The pooled RR (95% CI) for mortality of diabetic versus non-diabetic patients was significantly increased at 30 days (RR 1.64, 95% CI 1.39, 1.93), 1 year (RR 1.83, 95% CI 1.56, 2.15), 3 years (RR 1.81, 95% CI 1.58, 2.09), 5 years (RR 1.66, 95% CI 1.53, 1.79) and 10 years (RR 1.55, 95% CI 1.43, 1.68) after CABG. Significant differences were also found for DM versus non-DM patients post-CABG for perioperative cerebrovascular accidents (RR 1.52; 95% CI 1.31, 1.77), postoperative acute renal failure (RR 1.63; 95% CI 1.48, 1.79), sternal infection (RR; 1.70, 95% CI 1.41-2.04) and blood transfusion (RR 1.15; 95% CI 1.08, 1.21). No significant differences were found for postoperative atrial fibrillation (AF), postoperative myocardial infarction (MI) and re-exploration for bleeding. Insufficient and/or heterogeneous data did not allow for pooled analysis of ventilator time, ICU stay, angina recurrence, repeat revascularization, hospital stay and hospital costs.
Current evidence suggests that patients with DM who are undergoing CABG are at increased risk of mortality, stroke, renal failure, sternal infection and blood transfusion when compared to those without DM. This increased relative risk for perioperative mortality and complications has remained, despite evolving definitions of DM and practice patterns. Future randomized studies should focus on interventions targeted toward these complications to mitigate the risk for patients with DM.
由于临床试验在测量糖尿病与围手术期风险之间的关联时得出的结论相互矛盾，糖尿病（DM）对接受冠状动脉旁路移植（CABG）手术的患者的死亡率和发病率的影响仍不确定。因此，进行了一项定量荟萃分析，以评估前瞻性和历史性队列临床试验中获得的证据。本研究的目的是确定过去几十年和当代 CABG 患者中 DM 对死亡率、发病率和与资源相关的结果的影响的意义和程度。
通过 MEDILINE、EMBase、BIOSIS Preview、CBMDisc、CNKI 和 WanFang 数据库进行搜索，并通过手工搜索进行补充，无语言限制，检索 1981 年 1 月至 2008 年 10 月发表的研究。数据提取包括研究设计、设置、纳入/排除标准、人群特征、统计方法、随访时间和临床结果。对合格的研究进行质量评估。
在 132 项已确定的研究中，选择了 24 项具有 4.3 年中位随访时间的队列研究进行分析。共有 100217 名患者（28168 名患有糖尿病，72049 名没有糖尿病）纳入荟萃分析。与非糖尿病患者相比，糖尿病患者术后 30 天（RR 1.64，95%CI 1.39，1.93）、1 年（RR 1.83，95%CI 1.56，2.15）、3 年（RR 1.81，95%CI 1.58，2.09）、5 年（RR 1.66，95%CI 1.53，1.79）和 10 年（RR 1.55，95%CI 1.43，1.68）的死亡率显著增加。与非糖尿病患者相比，术后脑血管意外（RR 1.52；95%CI 1.31，1.77）、术后急性肾功能衰竭（RR 1.63；95%CI 1.48，1.79）、胸骨感染（RR 1.70，95%CI 1.41-2.04）和输血（RR 1.15；95%CI 1.08，1.21）也存在显著差异。术后心房颤动（AF）、术后心肌梗死（MI）和再次出血探查无显著差异。由于数据不足和/或异质性，不允许对通气时间、重症监护病房停留时间、心绞痛复发、再次血运重建、住院时间和住院费用进行汇总分析。
目前的证据表明，与非糖尿病患者相比，接受 CABG 的糖尿病患者的围手术期死亡率、中风、肾衰竭、胸骨感染和输血风险增加。尽管糖尿病的定义和实践模式不断发展，但这种围手术期死亡率和并发症的相对风险仍然存在。未来的随机研究应侧重于针对这些并发症的干预措施，以降低糖尿病患者的风险。
