From the Departments of Outcomes Research (D.I.S., N.M.Z., G.M.) and Quantitative Health Sciences (N.M.Z., G.M.), Cleveland Clinic, Cleveland, Ohio; the Department of Anaesthesia and Intensive Care, Bispebjerg Hospital (C.S.M.) and the Department of Anaesthesiology, Herlev Hospital (C.S.M., R.M.D.), University of Copenhagen, Copenhagen, Denmark; the Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia (K.L.); the Department of Research, Grupo de Cardiología Preventiva Universidad Autónoma de Bucaramanga, Fundación CardioInfantil Instituto de Cardiología, Bucaramanga, Colombia (S.M.V.); the Anaesthetic Department, Hull and East Yorkshire Hospitals, National Health Service Trust, Hull, East Yorkshire, United Kingdom (P.B.); Department of Cardiology, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, Universidad Autónoma de Barcelona, Barcelona (J.A.-G.); the Research Institute, Hospital do Coração, São Paulo, Brazil (A.B.C.); the Department of Anesthesia, Queen's University and Kingston General Hospital, Kingston, Canada (J.L.P.); Rahate Surgical Hospital, Nagpur, Maharashtra, India (P.V.R.); the Department of Anesthesia and Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland (M.D.S.); the Department of Vascular Surgery, Sapienza University of Rome, Rome, Italy (B.G.); Counties Manukau District Health, Aukland, New Zealand (S.A.W.); the Krishna Institute of Medical Sciences, Hyderbad, India (R.K.P.); the Department of Pediatrics, Hvidovre Hospital, Copenhagen, Denmark (R.M.D.); the Department of Anaesthetics, University of KwaZulu-Natal, Pietermaritzburg, South Africa (R.R.), the Hypertension and Vascular Aging Center, Hospital Universitario Austral, Pilar, Argentina (F.B.); the Departments of Health Research Methods, Evidence, and Impact and Medicine, McMaster University, Hamilton, Canada (P.J.D.); and the Population Health Research Institute, Hamilton, Canada (E.D., P.J.D., D.I.S.).
Anesthesiology. 2018 Feb;128(2):317-327. doi: 10.1097/ALN.0000000000001985.
The relative contributions of intraoperative and postoperative hypotension to perioperative morbidity remain unclear. We determined the association between hypotension and a composite of 30-day myocardial infarction and death over three periods: (1) intraoperative, (2) remaining day of surgery, and (3) during the initial four postoperative days.
This was a substudy of POISE-2, a 10,010-patient factorial-randomized trial of aspirin and clonidine for prevention of myocardial infarction. Clinically important hypotension was defined as systolic blood pressure less than 90 mmHg requiring treatment. Minutes of hypotension was the exposure variable intraoperatively and for the remaining day of surgery, whereas hypotension status was treated as binary variable for postoperative days 1 to 4. We estimated the average relative effect of hypotension across components of the composite using a distinct effect generalized estimating model, adjusting for hypotension during earlier periods.
Among 9,765 patients, 42% experienced hypotension, 590 (6.0%) had an infarction, and 116 (1.2%) died within 30 days of surgery. Intraoperatively, the estimated average relative effect across myocardial infarction and mortality was 1.08 (98.3% CI, 1.03, 1.12; P < 0.001) per 10-min increase in hypotension duration. For the remaining day of surgery, the odds ratio was 1.03 (98.3% CI, 1.01, 1.05; P < 0.001) per 10-min increase in hypotension duration. The average relative effect odds ratio was 2.83 (98.3% CI, 1.26, 6.35; P = 0.002) in patients with hypotension during the subsequent four days of hospitalization.
Clinically important hypotension-a potentially modifiable exposure-was significantly associated with a composite of myocardial infarction and death during each of three perioperative periods, even after adjustment for previous hypotension.
术中及术后低血压对围手术期发病率的相对影响仍不清楚。我们确定了低血压与 30 天内心肌梗死和死亡的复合指标之间的关系，该复合指标分为三个时期：（1）术中，（2）手术剩余日，以及（3）术后最初的 4 天。
这是 POISE-2 的一个亚研究，POISE-2 是一项涉及 10010 名患者的阿司匹林和可乐定预防心肌梗死的析因随机试验。临床显著低血压定义为收缩压低于 90mmHg 需要治疗。术中及手术剩余日的低血压时间为暴露变量，而术后第 1 至 4 天的低血压状态为二分类变量。我们使用特定的效应广义估计模型来估计复合指标中各组成部分的低血压平均相对效应，同时调整了前几个时期的低血压情况。
在 9765 名患者中，42%的患者发生了低血压，590 例（6.0%）发生了心肌梗死，116 例（1.2%）在术后 30 天内死亡。术中，低血压持续时间每增加 10 分钟，心肌梗死和死亡率的平均相对效应估计值为 1.08（98.3%置信区间，1.03，1.12；P <0.001）。在手术剩余日，低血压持续时间每增加 10 分钟，比值比为 1.03（98.3%置信区间，1.01，1.05；P <0.001）。在随后住院的 4 天内发生低血压的患者中，平均相对效应比值比为 2.83（98.3%置信区间，1.26，6.35；P =0.002）。
临床显著的低血压——一种潜在可改变的因素——与三个围手术期时期的心肌梗死和死亡复合指标显著相关，即使调整了之前的低血压情况也是如此。
