肾素血管紧张素拮抗剂与择期骨科手术患者围手术期不良事件的关联：一项病例对照研究。

Association of renin angiotensin antagonists with adverse perioperative events in patients undergoing elective orthopaedic surgery: a case-control study.

作者信息

Zainudheen Amith, Scott Ian A, Caney Xenia

机构信息

Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.

出版信息

Intern Med J. 2017 Sep;47(9):999-1005. doi: 10.1111/imj.13487.

DOI:10.1111/imj.13487

PMID:28509399

Abstract

BACKGROUND

Renin angiotensin antagonists (RAA) may block protective vasopressor responses during surgery. Evidence linking RAA with intraoperative hypotension and perioperative adverse events is conflicting.

AIM

To compare the incidence of intraoperative hypotension and adverse events between patients receiving or not receiving RAA.

METHODS

This is a retrospective case-control study of 258 consecutive patients who underwent elective total knee or hip replacement between 1 January 2013 and 31 August 2016 and who were chronically prescribed a single blood pressure-lowering agent up to the time of surgery. Primary outcome measures were differences between patients receiving RAA (cases; n = 129) and patients receiving non-RAA medications (controls; n = 129) in incidence of intraoperative hypotension (systolic blood pressure <90 mmHg), perioperative acute kidney injury (AKI, >30% increase in serum creatinine from baseline on Day 1 post-operatively) and new onset major adverse cardiac or cerebrovascular events (MACCE) or in-hospital death over 72 h post-operatively.

RESULTS

Patients receiving RAA had significantly higher preoperative systolic blood pressure, greater prevalence of hypertension and chronic kidney disease, lower prevalence of ischaemic heart disease and lower cardiac risk compared to controls. Age, gender, type of operation, operative fitness, mode and duration of anaesthesia and prevalence of other types of cardiovascular disease, dyslipidaemia and diabetes were similar between groups. Compared to controls, patients receiving RAA had higher incidence of intraoperative hypotension (76.0 vs 45.9%, P < 0.001), AKI (11.6 vs 1.6%, P = 0.002) and MACCE (6.2 vs 0%, P = 0.007), with all adverse events associated with intraoperative hypotension.

CONCLUSION

This study provides further observational evidence of RAA-induced harm in patients undergoing elective surgery, although determining benefits and harms of preoperative withdrawal of RRA requires prospective randomised trials.

摘要

背景

肾素血管紧张素拮抗剂（RAA）可能会阻断手术期间的保护性血管加压反应。将RAA与术中低血压和围手术期不良事件联系起来的证据相互矛盾。

目的

比较接受或未接受RAA的患者术中低血压和不良事件的发生率。

方法

这是一项回顾性病例对照研究，研究对象为2013年1月1日至2016年8月31日期间连续接受择期全膝关节或髋关节置换术且在手术前长期服用单一降压药的258例患者。主要观察指标为接受RAA的患者（病例组；n = 129）与接受非RAA药物的患者（对照组；n = 129）在术中低血压（收缩压<90 mmHg）、围手术期急性肾损伤（AKI，术后第1天血清肌酐较基线升高>30%）、新发主要不良心脏或脑血管事件（MACCE）或术后72小时内住院死亡发生率方面的差异。

结果

与对照组相比，接受RAA的患者术前收缩压显著更高，高血压和慢性肾病患病率更高，缺血性心脏病患病率更低，心脏风险更低。两组在年龄、性别、手术类型、手术适应性、麻醉方式和持续时间以及其他类型心血管疾病、血脂异常和糖尿病的患病率方面相似。与对照组相比，接受RAA的患者术中低血压（76.0%对45.9%，P < 0.001）、AKI（11.6%对1.6%，P = 0.002）和MACCE（6.2%对0%，P = 0.007）的发生率更高，所有不良事件均与术中低血压相关。