术前心率升高与高危手术患者心肺和自主神经功能损害有关。

Elevated preoperative heart rate is associated with cardiopulmonary and autonomic impairment in high-risk surgical patients.

机构信息

William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK.

Peninsula Medical School, Plymouth, UK.

出版信息

Br J Anaesth. 2017 Jul 1;119(1):87-94. doi: 10.1093/bja/aex164.

DOI:10.1093/bja/aex164

PMID:28974075

Abstract

BACKGROUND

Elevated preoperative heart rate (HR) is associated with perioperative myocardial injury and death. In apparently healthy individuals, high resting HR is associated with development of cardiac failure. Given that patients with overt cardiac failure have poor perioperative outcomes, we hypothesized that subclinical cardiac failure, identified by cardiopulmonary exercise testing, was associated with elevated preoperative HR > 87 beats min -1 (HR > 87).

METHODS

This was a secondary analysis of an observational cohort study of surgical patients aged ≥45 yr. The exposure of interest was HR > 87, recorded at rest before preoperative cardiopulmonary exercise testing. The predefined outcome measures were the following established predictors of mortality in patients with overt cardiac failure in the general population: ventilatory equivalent for carbon dioxide ( V˙E/V˙co2 ) ratio ≥34, heart rate recovery ≤6 and peak oxygen uptake ( V˙o2 ) ≤14 ml kg -1 min -1 . We used logistic regression analysis to test for association between HR > 87 and markers of cardiac failure. We also examined the relationship between HR > 87 and preoperative left ventricular stroke volume in a separate cohort of patients.

RESULTS

HR > 87 was present in 399/1250 (32%) patients, of whom 438/1250 (35%) had V˙E/V˙co2 ratio ≥34, 200/1250 (16%) had heart rate recovery ≤6, and 396/1250 (32%) had peak V˙o2 ≤14 ml kg -1 min -1 . HR > 87 was independently associated with peak V˙o2 ≤14 ml kg -1 min -1 {odds ratio (OR) 1.69 [1.12-3.55]; P =0.01} and heart rate recovery ≤6 (OR 2.02 [1.30-3.14]; P <0.01). However, HR > 87 was not associated with V˙E/V˙co2 ratio ≥34 (OR 1.31 [0.92-1.87]; P =0.14). In a separate cohort, HR > 87 (33/181; 18.5%) was associated with impaired preoperative stroke volume (OR 3.21 [1.26-8.20]; P =0.01).

CONCLUSIONS

Elevated preoperative heart rate is associated with impaired cardiopulmonary performance consistent with clinically unsuspected, subclinical cardiac failure.

CLINICAL TRIAL REGISTRATION

ISRCTN88456378.

摘要

背景

术前心率（HR）升高与围手术期心肌损伤和死亡有关。在看似健康的个体中，静息 HR 升高与心力衰竭的发展有关。鉴于有明显心力衰竭的患者围手术期结局较差，我们假设通过心肺运动试验识别出的亚临床心力衰竭与术前 HR>87 次/分（HR>87）有关。

方法

这是一项对≥45 岁手术患者的观察性队列研究的二次分析。感兴趣的暴露是术前心肺运动试验前休息时记录的 HR>87。预先设定的结局指标是以下在一般人群中已确定的有明显心力衰竭患者的死亡率预测因子：二氧化碳通气当量（V˙E/V˙co2）比≥34，心率恢复≤6 和峰值摄氧量（V˙o2）≤14 ml·kg-1·min-1。我们使用逻辑回归分析来检验 HR>87 与心力衰竭标志物之间的关联。我们还在另一批患者中检查了 HR>87 与术前左心室每搏量之间的关系。

结果

在 1250 名患者中，有 399 名（32%）患者存在 HR>87，其中 438 名（35%）患者 V˙E/V˙co2 比≥34，200 名（16%）患者心率恢复≤6，396 名（32%）患者峰值 V˙o2≤14 ml·kg-1·min-1。HR>87 与峰值 V˙o2≤14 ml·kg-1·min-1 独立相关（优势比[OR] 1.69[1.12-3.55]；P=0.01）和心率恢复≤6（OR 2.02[1.30-3.14]；P<0.01）。然而，HR>87 与 V˙E/V˙co2 比≥34 无关（OR 1.31[0.92-1.87]；P=0.14）。在另一批患者中，HR>87（33/181；18.5%）与术前每搏量受损有关（OR 3.21[1.26-8.20]；P=0.01）。