Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and The London Medical School, Queen Mary University of London, London EC1M, UK.
Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and The London Medical School, Queen Mary University of London, London EC1M, UK.
Br J Anaesth. 2018 Jan;120(1):94-100. doi: 10.1016/j.bja.2017.11.009. Epub 2017 Nov 21.
Systemic arterial pulse pressure (systolic minus diastolic pressure) ≤53 mm Hg in patients with cardiac failure is correlated with reduced stroke volume and is independently associated with accelerated morbidity and mortality. Given that deconditioned surgical and heart failure patients share similar cardiopulmonary physiology, we examined whether lower pulse pressure is associated with excess morbidity after major surgery.
This was a prospective observational cohort study of patients deemed by their preoperative assessors to be at higher risk of postoperative morbidity. Preoperative pulse pressure was calculated before cardiopulmonary exercise testing. The primary outcome was any morbidity (PostOperative Morbidity Survey) occurring within 5 days of surgery, stratified by pulse pressure threshold ≤53 mm Hg. The relationship between pulse pressure, postoperative morbidity, and oxygen pulse (a robust surrogate for left ventricular stroke volume) was examined using logistic regression analysis (accounting for age, sex, BMI, cardiometabolic co-morbidity, and operation type).
The primary outcome occurred in 578/660 (87.6%) patients, but postoperative morbidity was more common in 243/ 660 patients with preoperative pulse pressure ≤53 mm Hg{odds ratio (OR): 2.24 [95% confidence interval (CI): 1.29-3.38]; P<0.001). Pulse pressure ≤53 mm Hg [OR:1.23 (95% CI: 1.03-1.46); P=0.02] and type of surgery were independently associated with all-cause postoperative morbidity (multivariate analysis). Oxygen pulse <90% of population-predicted normal values was associated with pulse pressure ≤ 53 mm Hg [OR: 1.93 (95% CI: 1.32-2.84); P=0.007].
In deconditioned surgical patients, lower preoperative systemic arterial pulse pressure is associated with excess morbidity. These data are strikingly similar to meta-analyses identifying low pulse pressure as an independent risk factor for adverse outcomes in cardiac failure. Low preoperative pulse pressure is a readily available measure, indicating that detailed physiological assessment may be warranted.
ISRCT registry, ISRCTN88456378.
心力衰竭患者的系统性动脉脉搏压（收缩压减去舒张压）≤53mmHg 与每搏量减少有关，并且与发病率和死亡率的加速独立相关。鉴于未适应手术和心力衰竭患者具有相似的心肺生理学，我们研究了主要手术后较低的脉搏压是否与发病率增加有关。
这是一项前瞻性观察性队列研究，研究对象为术前评估者认为术后发病率较高的患者。在心肺运动测试前计算术前脉搏压。主要结局是手术 5 天内发生的任何发病率（术后发病率调查），并按脉搏压阈值≤53mmHg 进行分层。使用逻辑回归分析（考虑年龄、性别、BMI、心脏代谢合并症和手术类型）检查脉搏压、术后发病率和氧脉冲（左心室每搏量的可靠替代指标）之间的关系。
主要结局发生在 578/660（87.6%）例患者中，但 243/660 例术前脉搏压≤53mmHg 的患者中更常见术后发病率（优势比[OR]：2.24[95%置信区间（CI）：1.29-3.38]；P<0.001）。脉搏压≤53mmHg[OR：1.23（95%CI：1.03-1.46）；P=0.02]和手术类型与所有原因的术后发病率独立相关（多变量分析）。氧脉冲<90%人群预测正常值与脉搏压≤53mmHg 相关[OR：1.93（95%CI：1.32-2.84）；P=0.007]。
在未适应手术的患者中，较低的术前系统性动脉脉搏压与发病率增加有关。这些数据与荟萃分析非常相似，该分析确定低脉搏压是心力衰竭不良结局的独立危险因素。术前低脉搏压是一种易于获得的测量指标，表明可能需要进行详细的生理评估。
ISRCTN 注册表，ISRCTN88456378。
