Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
J Am Coll Surg. 2011 Jun;212(6):1018-26. doi: 10.1016/j.jamcollsurg.2011.02.018. Epub 2011 Mar 26.
Recent studies suggest that preoperative coronary revascularization overall does not improve outcomes after noncardiac surgery. It is not known whether this holds true for high-risk patients with a history of recent MI. Our objective was to determine whether preoperative revascularization improves outcomes after noncardiac surgery in patients with a recent MI.
Using the California Patient Discharge Database, we retrospectively analyzed patients with a recent MI who underwent hip surgery, cholecystectomy, bowel resection, elective abdominal aortic aneurysm repair, and lower extremity amputation from 1999 to 2004 (n = 16,478). Postoperative 30-day reinfarction and 30-day and 1-year mortality were compared for patients who underwent preoperative revascularization (percutaneous transluminal coronary angioplasty, coronary stenting, or coronary artery bypass graft) and those who were not revascularized using univariate analyses and multivariate logistic regression. Relative risks with 95% confidence intervals were estimated using bootstrapping with 1,000 repetitions.
Patients with a recent MI who were revascularized before surgery had an approximately 50% decreased rate of reinfarction (5.1% versus 10.0%; p < 0.001) and 30-day (5.2% versus 11.3%; p < 0.001) and 1-year mortality (18.3% versus 35.8%; p < 0.001) compared with those who were not. Stenting within 1 month of surgery was associated with a trend toward increased reinfarction (relative risk: 1.36; 95% CI, 0.96-1.97), and coronary artery bypass graft was associated with a decreased risk (relative risk: 0.70; 95% CI, 0.55-0.95).
This large sample representing real world practice suggests that patients with a recent MI can benefit from preoperative revascularization. Coronary artery bypass graft can improve outcomes more than stenting, especially when surgery is necessary within 1 month of revascularization, but additional prospective studies are indicated.
最近的研究表明，非心脏手术后，整体上术前冠状动脉血运重建并不能改善结果。对于近期心肌梗死病史的高危患者，这是否仍然成立尚不清楚。我们的目的是确定近期心肌梗死患者非心脏手术后，术前血运重建是否改善结果。
利用加利福尼亚州患者出院数据库，我们回顾性分析了 1999 年至 2004 年期间接受髋关节手术、胆囊切除术、肠切除术、择期腹主动脉瘤修复术和下肢截肢术的近期心肌梗死患者（n=16478）。使用单变量分析和多变量逻辑回归比较接受术前血运重建（经皮腔内冠状动脉血管成形术、冠状动脉支架置入术或冠状动脉旁路移植术）和未血运重建的患者的术后 30 天再梗死以及 30 天和 1 年死亡率。使用 1000 次重复的自举法估计相对风险和 95%置信区间。
手术前接受血运重建的近期心肌梗死患者的再梗死率（5.1%对 10.0%；p<0.001）和 30 天（5.2%对 11.3%；p<0.001）和 1 年死亡率（18.3%对 35.8%；p<0.001）均降低约 50%。手术 1 个月内支架置入与再梗死率增加趋势相关（相对风险：1.36；95%CI，0.96-1.97），而冠状动脉旁路移植术与降低的风险相关（相对风险：0.70；95%CI，0.55-0.95）。
这项代表真实世界实践的大样本研究表明，近期心肌梗死患者可以从术前血运重建中获益。冠状动脉旁路移植术比支架置入术能改善结果，尤其是在血运重建后 1 个月内需要手术时，但需要进一步的前瞻性研究。
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