冠状动脉搭桥手术后的血小板计数与术后中风
Platelet Counts and Postoperative Stroke After Coronary Artery Bypass Grafting Surgery.
作者信息
Karhausen Jörn A, Smeltz Alan M, Akushevich Igor, Cooter Mary, Podgoreanu Mihai V, Stafford-Smith Mark, Martinelli Susan M, Fontes Manuel L, Kertai Miklos D
机构信息
Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
出版信息
Anesth Analg. 2017 Oct;125(4):1129-1139. doi: 10.1213/ANE.0000000000002187.
BACKGROUND
Declining platelet counts may reveal platelet activation and aggregation in a postoperative prothrombotic state. Therefore, we hypothesized that nadir platelet counts after on-pump coronary artery bypass grafting (CABG) surgery are associated with stroke.
METHODS
We evaluated 6130 adult CABG surgery patients. Postoperative platelet counts were evaluated as continuous and categorical (mild versus moderate to severe) predictors of stroke. Extended Cox proportional hazard regression analysis with a time-varying covariate for daily minimum postoperative platelet count assessed the association of day-to-day variations in postoperative platelet count with time to stroke. Competing risks proportional hazard regression models examined associations between day-to-day variations in postoperative platelet counts with timing of stroke (early: 0-1 days; delayed: ≥2 days).
RESULTS
Median (interquartile range) postoperative nadir platelet counts were 123.0 (98.0-155.0) × 10/L. The incidences of postoperative stroke were 1.09%, 1.50%, and 3.02% for platelet counts >150 × 10/L, 100 to 150 × 10/L, and <100 × 10/L, respectively. The risk for stroke increased by 12% on a given postoperative day for every 30 × 10/L decrease in platelet counts (adjusted hazard ratio [HR], 1.12; 95% confidence interval [CI], 1.01-1.24; P= .0255). On a given day, patients with moderate to severe thrombocytopenia were almost twice as likely to develop stroke (adjusted HR, 1.89; 95% CI, 1.13-3.16; P= .0155) as patients with nadir platelet counts >150 × 10/L. Importantly, such thrombocytopenia, defined as a time-varying covariate, was significantly associated with delayed (≥2 days after surgery; adjusted HR, 2.83; 95% CI, 1.48-5.41; P= .0017) but not early postoperative stroke.
CONCLUSIONS
Our findings suggest an independent association between moderate to severe postoperative thrombocytopenia and postoperative stroke, and timing of stroke after CABG surgery.
背景
血小板计数下降可能提示术后血栓形成状态下的血小板激活和聚集。因此，我们推测体外循环冠状动脉旁路移植术（CABG）后血小板计数最低点与中风有关。
方法
我们评估了6130例成年CABG手术患者。术后血小板计数被评估为中风的连续和分类（轻度与中度至重度）预测指标。采用扩展Cox比例风险回归分析，对术后每日最低血小板计数进行时变协变量分析，评估术后血小板计数的每日变化与中风发生时间的关联。竞争风险比例风险回归模型检验了术后血小板计数的每日变化与中风时间（早期：0 - 1天；延迟：≥2天）之间的关联。
结果
术后血小板计数最低点的中位数（四分位间距）为123.0（98.0 - 155.0）×10⁹/L。血小板计数>150×10⁹/L、100至150×10⁹/L和<100×10⁹/L的患者术后中风发生率分别为1.09%、1.50%和3.02%。术后血小板计数每降低30×10⁹/L，中风风险在术后某一天增加12%（调整后的风险比[HR]，1.12；95%置信区间[CI]，1.01 - 1.24；P = 0.0255）。在某一天，中度至重度血小板减少的患者发生中风的可能性几乎是血小板计数最低点>150×10⁹/L患者的两倍（调整后的HR，1.89；95% CI，1.13 - 3.16；P = 0.0155）。重要的是，这种定义为时变协变量的血小板减少与延迟性（手术后≥2天；调整后的HR，2.83；95% CI，1.48 - 5.41；P = 0.0017）而非早期术后中风显著相关。
结论
我们的研究结果表明，中度至重度术后血小板减少与术后中风以及CABG手术后中风的时间之间存在独立关联。
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