Holcomb Carla N, Graham Laura A, Richman Joshua S, Itani Kamal M F, Maddox Thomas M, Hawn Mary T
*Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL †The Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham Veterans Administration Hospital, Birmingham, AL ‡Department of Surgery, VA Boston Health Care System, Boston University and Harvard Medical School, Boston, MA §VA Eastern Colorado Health Care System, Denver, CO ¶University of Colorado School of Medicine, Denver, CO.
Ann Surg. 2016 May;263(5):924-30. doi: 10.1097/SLA.0000000000001246.
To determine the incremental risk of coronary stents on adverse events in surgical patients and whether it varies over time from stent placement.
Postoperative adverse cardiac events decrease as the time from stent placement increases, but the risk attributable to the stent versus the underlying cardiac disease is uncertain, as prior studies lack a control surgical population.
Data for patients with coronary stents implanted in a VA hospital from 2000 to 2010 were matched with VA Surgical Quality Improvement Program data to identify noncardiac surgery within 24 months of stent placement. Each patient with stent was matched with 2 surgical patients without stent on surgical characteristics and cardiac risk factors. Outcomes of myocardial infarction (MI), revascularization, and death within 30 days after surgery were modeled using logistic regression. Adjusted risk differences between stented and nonstented populations were compared across time after stent placement.
Adverse cardiac events followed surgery in 531 (5.7%) of the 9391 patients with stent and 680 (3.6%) of the 18,782 patients without stent (P < 0.001). In adjusted models, 30-day postoperative MI (odds ratio = 1.90; 95% confidence interval, 1.57-2.30) and revascularization (odds ratio = 2.03; 95% confidence interval, 1.65-2.50) but not mortality (odds ratio = 0.84; 95% confidence interval, 0.69-1.02) were higher in the stented cohort. Assessing trends over the 2 years after stent placement, the incremental risk for MI decreased from 5% immediately after stent placement to 2% at 1 year and then was no longer significantly elevated. The incremental risk did not vary by stent type.
Surgery after coronary stent placement is associated with an approximate 2% absolute risk for postoperative MI but no difference in mortality compared with nonstented matched controls.
确定冠状动脉支架植入术对手术患者不良事件的增量风险，以及该风险是否随支架植入后的时间变化而有所不同。
随着距支架植入时间的增加，术后不良心脏事件会减少，但与潜在心脏疾病相比，支架植入所致的风险尚不确定，因为既往研究缺乏对照手术人群。
将2000年至2010年在一家退伍军人事务部（VA）医院植入冠状动脉支架的患者数据与VA手术质量改进项目数据进行匹配，以确定在支架植入后24个月内进行的非心脏手术。根据手术特征和心脏危险因素，为每名植入支架的患者匹配2名未植入支架的手术患者。采用逻辑回归对术后30天内心肌梗死（MI）、血运重建和死亡的结局进行建模。比较支架植入后不同时间点植入支架和未植入支架人群之间经调整的风险差异。
9391例植入支架的患者中有531例（5.7%）术后发生不良心脏事件，18782例未植入支架的患者中有680例（3.6%）发生不良心脏事件（P<0.001）。在调整模型中，植入支架的队列术后30天MI（比值比=1.90；95%置信区间为1.57 - 2.30）和血运重建（比值比=2.03；95%置信区间为1.65 - 2.50）的发生率较高，但死亡率（比值比=0.84；95%置信区间为0.69 - 1.02）无差异。评估支架植入后2年内的趋势，MI的增量风险从支架植入后即刻的5%降至1年时的2%，之后不再显著升高。增量风险不因支架类型而异。
冠状动脉支架植入术后进行手术，术后MI的绝对风险约为2%，但与未植入支架的匹配对照组相比，死亡率无差异。
