William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK.
Barts Health NHS Trust, London E1?1BB, UK.
Br J Anaesth. 2017 Jul 1;119(1):78-86. doi: 10.1093/bja/aex165.
The management of elevated blood pressure before non-cardiac surgery remains controversial. Pulse pressure is a stronger predictor of cardiovascular morbidity in the general population than systolic blood pressure alone. We hypothesized that preoperative pulse pressure was associated with perioperative myocardial injury.
This is a secondary analysis of the Vascular Events in Non-cardiac Surgery Patients Cohort Evaluation (VISION) international cohort study. Participants were aged ≥45 yr and undergoing non-cardiac surgery at 12 hospitals in eight countries. The primary outcome was myocardial injury, defined using serum troponin concentration, within 30 days after surgery. The sample was stratified into quintiles by preoperative pulse pressure. Multivariable logistic regression analysis explored associations between pulse pressure and myocardial injury. We accounted for potential confounding by systolic blood pressure and other co-morbidities known to be associated with postoperative cardiovascular complications.
One thousand one hundred and ninety-one of 15 057 (7.9%) patients sustained myocardial injury, which was more frequent amongst patients in the highest two preoperative pulse pressure quintiles {63-75 mm Hg, risk ratio (RR) 1.14 [95% confidence interval (CI): 1.01-1.28], P =0.03; >75 mm Hg, RR 1.15 [95% CI: 1.03-1.29], P =0.02}. After adjustment for systolic blood pressure, preoperative pulse pressure remained the dominant predictor of myocardial injury (63-75 mm Hg, RR 1.20 [95% CI: 1.05-1.37], P <0.01; >75 mm Hg, RR 1.25 [95% CI: 1.06-1.48], P <0.01). Systolic blood pressure >160 mm Hg was not associated with myocardial injury in the absence of pulse pressure >62 mm Hg (RR 0.67 [95% CI: 0.30-1.44], P =0.31).
Preoperative pulse pressure >62 mm Hg was associated with myocardial injury, independent of systolic blood pressure. Elevated pulse pressure may be a useful clinical sign to guide strategies to reduce perioperative myocardial injury.
非心脏手术前高血压的管理仍存在争议。脉压是一般人群心血管发病率的比单纯收缩压更强的预测因素。我们假设术前脉压与围手术期心肌损伤有关。
这是血管事件在非心脏手术患者队列评估（VISION）国际队列研究的二次分析。参与者年龄≥45 岁，在 8 个国家的 12 家医院接受非心脏手术。主要结果是术后 30 天内的心肌损伤，通过血清肌钙蛋白浓度定义。样本按术前脉压分为五分位数。多变量逻辑回归分析探讨了脉压与心肌损伤之间的关系。我们通过收缩压和其他已知与术后心血管并发症相关的合并症来解释潜在的混杂因素。
在 15057 名患者中，有 1191 名（7.9%）发生了心肌损伤，在术前脉压最高的两个五分位数患者中更为常见{63-75mmHg，风险比（RR）1.14（95%置信区间[CI]：1.01-1.28），P=0.03；>75mmHg，RR 1.15（95%CI：1.03-1.29），P=0.02}。调整收缩压后，术前脉压仍然是心肌损伤的主要预测因素（63-75mmHg，RR 1.20（95%CI：1.05-1.37），P<0.01；>75mmHg，RR 1.25（95%CI：1.06-1.48），P<0.01）。在没有脉压>62mmHg 的情况下，收缩压>160mmHg 与心肌损伤无关（RR 0.67（95%CI：0.30-1.44），P=0.31）。
术前脉压>62mmHg 与心肌损伤有关，独立于收缩压。脉压升高可能是指导减少围手术期心肌损伤策略的有用临床指标。
