Ann Intern Med. 2015 Jul 21;163(2):107-17. doi: 10.7326/M14-2793.
Risks for intermediate- and long-term cognitive impairment after cardiovascular procedures in older adults are poorly understood.
To summarize evidence about cognitive outcomes in adults aged 65 years or older at least 3 months after coronary or carotid revascularization, cardiac valve procedures, or ablation for atrial fibrillation.
MEDLINE, Cochrane, and Scopus databases from 1990 to January 2015; ClinicalTrials.gov; and bibliographies of reviews and eligible studies.
English-language trials and prospective cohort studies.
One reviewer extracted data, a second checked accuracy, and 2 independently rated quality and strength of evidence (SOE).
17 trials and 4 cohort studies were included; 80% of patients were men, and mean age was 68 years. Cognitive function did not differ after the procedure between on- and off-pump coronary artery bypass grafting (CABG) (n = 6; low SOE), hypothermic and normothermic CABG (n = 3; moderate to low SOE), or CABG and medical management (n = 1; insufficient SOE). One trial reported lower risk for incident cognitive impairment with minimal versus conventional extracorporeal CABG (risk ratio, 0.34 [95% CI, 0.16 to 0.73]; low SOE). Two trials found no difference between surgical carotid revascularization and carotid stenting or angioplasty (low and insufficient SOE, respectively). One cohort study reported increased cognitive decline after transcatheter versus surgical aortic valve replacement but had large selection and outcome measurement biases (insufficient SOE).
Mostly low to insufficient SOE; no pertinent data for ablation; limited generalizability to the most elderly patients, women, and persons with substantial baseline cognitive impairment; and possible selective reporting and publication bias.
Intermediate- and long-term cognitive impairment in older adults attributable to the studied cardiovascular procedures may be uncommon. Nevertheless, clinicians counseling patients before these procedures should discuss the uncertainty in their risk for adverse cognitive outcomes.
Agency for Healthcare Research and Quality.
老年人在心血管手术后发生中、长期认知障碍的风险还不太清楚。
总结 65 岁及以上成人在冠状动脉或颈动脉血运重建、心脏瓣膜手术或房颤消融术后至少 3 个月时认知结局的证据。
从 1990 年到 2015 年 1 月，检索 MEDLINE、Cochrane 和 Scopus 数据库、ClinicalTrials.gov 以及相关综述和合格研究的参考文献。
英语试验和前瞻性队列研究。
1 位研究者提取数据，另 1 位研究者核对准确性，2 位研究者独立评价质量和证据强度（SOE）。
纳入 17 项试验和 4 项队列研究；80%的患者为男性，平均年龄 68 岁。与非体外循环冠状动脉旁路移植术（CABG）相比，体外循环与非体外循环 CABG（低 SOE）、低温与常温 CABG（中到低 SOE）或 CABG 与药物治疗（低 SOE）后认知功能无差异；1 项试验报告微创与常规体外 CABG 相比，发生认知障碍的风险较低（风险比，0.34[95%CI，0.16 至 0.73]；低 SOE）。2 项试验发现，颈动脉血运重建与颈动脉支架置入或血管成形术之间无差异（分别为低和不足的 SOE）。1 项队列研究报告经导管与外科主动脉瓣置换相比，认知功能下降更明显，但存在较大的选择和结局测量偏倚（不足的 SOE）。
主要为低到不足的 SOE；无消融相关的相关数据；对最年长的患者、女性和有大量基线认知障碍的患者的适用性有限；可能存在选择性报告和发表偏倚。
在接受研究的心血管手术的老年患者中，中、长期认知障碍可能不常见。然而，在为这些患者提供治疗前，临床医生应与患者讨论其发生不良认知结局的风险不确定。
美国医疗保健研究与质量局。
