Patel Akshay J, Som Robin
Department of Cardiothoracic Surgery, St George's Medical School, London, UK.
Interact Cardiovasc Thorac Surg. 2013 Mar;16(3):356-60. doi: 10.1093/icvts/ivs483. Epub 2012 Dec 2.
A best evidence topic was written according to a structured protocol. The question addressed was what is the optimum prophylaxis against gastrointestinal haemorrhage for patients undergoing adult cardiac surgery: histamine receptor antagonists (H(2)RA) or proton-pump inhibitors? A total of 201 papers were found; of which, 8 represented the best evidence. The authors, date, journal, study type, population, main outcome measures and results were tabulated. Only one randomized controlled trial (RCT) with relevant clinical outcomes was identified. The rest of the studies consisted of five prospective studies and two retrospective studies. In the RCT, there were no reported cases of gastrointestinal haemorrhage in the proton-pump inhibitor cohort, whereas 4 patients taking H(2)RA developed it. The rate of active gastrointestinal ulceration was higher in the H(2)RA cohort in comparison with the proton-pump inhibitor cohort (21.4 vs 4.3%). A prospective study followed 2285 consecutive patients undergoing cardiac surgery who received either no prophylaxis, or a proton-pump inhibitor. Chi-squared analysis showed the risk of bleeding to be lower in those receiving the proton-pump inhibitor (P < 0.05). Another study of 6316 patients undergoing coronary artery bypass grafting demonstrated a reduced risk of gastrointestinal bleed with prophylactic intravenous omeprazole (odds ratio = 0.2; confidence intervals = 0.1-0.8; P < 0.05). One study successfully showed that proton-pump inhibitors are effective in adequately suppressing gastric acid levels, regardless of Helicobacter pylori infection status; conversely, this study suggested that H(2)RAs were not. The evidence for H(2)RAs is marginal, with no study showing a clear benefit. One study showed that ulcer prophylaxis with H(2)RA did not correlate with the clinical outcome. Another study demonstrated gastric ulceration to be a common gastrointestinal complication in spite of regular H(2)RA use. There is also evidence to suggest that acid suppression increases the risk of nosocomial pneumonia, although open heart surgery may be a confounding factor in this association. Two RCTs showed that H(2)RAs may augment the immune system and reducing stress following cardiac surgery. Proton-pump inhibitors appear to be the superior agent for prophylaxis against gastrointestinal bleed in patients undergoing cardiac surgery, although rigorous comparative data are sparse. Furthermore, level-I evidence would confirm this.
根据结构化方案撰写了一篇最佳证据主题。所探讨的问题是，对于接受成人心脏手术的患者，预防胃肠道出血的最佳药物是什么：组胺受体拮抗剂（H(2)RA）还是质子泵抑制剂？共检索到201篇论文，其中8篇代表了最佳证据。对作者、日期、期刊、研究类型、人群、主要结局指标和结果进行了列表整理。仅确定了一项具有相关临床结局的随机对照试验（RCT）。其余研究包括五项前瞻性研究和两项回顾性研究。在RCT中，质子泵抑制剂组未报告胃肠道出血病例，而4例服用H(2)RA的患者出现了胃肠道出血。与质子泵抑制剂组相比，H(2)RA组的活动性胃溃疡发生率更高（21.4%对4.3%）。一项前瞻性研究对2285例连续接受心脏手术的患者进行了随访，这些患者要么未接受预防治疗，要么接受了质子泵抑制剂治疗。卡方分析显示，接受质子泵抑制剂治疗的患者出血风险较低（P < 0.05）。另一项对6316例接受冠状动脉搭桥术的患者进行的研究表明，预防性静脉注射奥美拉唑可降低胃肠道出血风险（比值比 = 0.2；置信区间 = 0.1 - 0.8；P < 0.05）。一项研究成功表明，无论幽门螺杆菌感染状况如何，质子泵抑制剂均能有效充分抑制胃酸水平；相反，该研究表明H(2)RA不能。H(2)RA的证据很有限，没有研究显示出明显益处。一项研究表明，用H(2)RA预防溃疡与临床结局无关。另一项研究表明，尽管定期使用H(2)RA，胃溃疡仍是常见的胃肠道并发症。也有证据表明，抑酸会增加医院获得性肺炎的风险，尽管心脏直视手术可能是这种关联中的一个混杂因素。两项RCT表明，H(2)RA可能增强免疫系统并减轻心脏手术后的应激反应。质子泵抑制剂似乎是预防心脏手术患者胃肠道出血的更佳药物，尽管严格的比较数据很少。此外，一级证据将证实这一点。
