From the Anesthesiology Institute.
Department of Cardiothoracic Anesthesia.
Anesth Analg. 2020 Nov;131(5):1491-1499. doi: 10.1213/ANE.0000000000005124.
Increased pulse pressure has been associated with adverse cardiovascular events, cardiac and all-cause mortality in surgical and nonsurgical patients. Whether increased pulse pressure worsens myocardial injury and dysfunction after cardiac surgery, however, has not been fully characterized. We examined whether cardiac surgical patients with elevated pulse pressure are more susceptible to myocardial injury, dysfunction, cardiac-related complications, and mortality. Secondarily, we examined whether pulse pressure was a stronger predictor of the outcomes than systolic blood pressure.
This retrospective observational study included adult cardiac surgical patients having elective isolated on-pump coronary artery bypass grafting (CABG) between 2010 and 2017 at the Cleveland Clinic. The association between elevated pulse pressure and (1) perioperative myocardial injury, measured by postoperative troponin-T concentrations, (2) perioperative myocardial dysfunction, assessed by the requirement for perioperative inotropic support using the modified inotropic score (MIS), and (3) cardiovascular complications assessed by the composite outcome of postoperative mechanical circulatory assistance or in-hospital mortality were assessed using multivariable linear regression models. Secondarily, the association between pulse pressure versus systolic blood pressure and the outcomes were compared.
Of 2704 patients who met the inclusion/exclusion criteria, complete data were available for 2003 patients. Increased pulse pressure over 40 mm Hg was associated with elevated postoperative troponin-T level, estimated to be 1.05 (97.5% confidence interval [CI], 1.02-1.09; P < .001) times higher per 10 mm Hg increase in pulse pressure. The association between pulse pressure and myocardial dysfunction and the composite outcome of cardiovascular complications and death were not significant. There was no difference in the association with pulse pressure versus systolic blood pressure and troponin-T concentrations.
Elevated preoperative pulse pressure was associated with a modest increase in postoperative troponin-T concentrations, but not postoperative cardiovascular complications or in-hospital mortality in patients having CABG. Pulse pressure was not a better predictor than systolic blood pressure.
在外科和非外科患者中，脉压升高与不良心血管事件、心脏和全因死亡率相关。然而，心脏手术后脉压升高是否会加重心肌损伤和功能障碍尚未完全阐明。我们研究了心脏手术患者中脉压升高是否更容易发生心肌损伤、功能障碍、与心脏相关的并发症和死亡率。其次，我们研究了脉压是否比收缩压更能预测这些结果。
本回顾性观察性研究纳入了 2010 年至 2017 年期间在克利夫兰诊所行择期体外循环冠状动脉旁路移植术（CABG）的成年心脏手术患者。通过术后肌钙蛋白 T 浓度评估围手术期心肌损伤、通过改良正性肌力评分（MIS）评估围手术期心肌功能障碍的发生率、通过术后机械循环辅助或院内死亡率的复合终点评估心血管并发症的发生率，采用多变量线性回归模型来评估升高的脉压与（1）围手术期心肌损伤，（2）围手术期心肌功能障碍，（3）心血管并发症之间的相关性。其次，比较了脉压与收缩压与这些结果之间的相关性。
在符合纳入/排除标准的 2704 例患者中，有 2003 例患者的完整数据可用。脉压升高超过 40mmHg 与术后肌钙蛋白 T 水平升高相关，估计每升高 10mmHg 脉压，术后肌钙蛋白 T 水平升高 1.05（97.5%置信区间 [CI]，1.02-1.09；P<.001）倍。脉压与心肌功能障碍和心血管并发症及死亡的复合终点之间的相关性不显著。脉压与收缩压和肌钙蛋白 T 浓度的相关性无差异。
在接受 CABG 的患者中，术前脉压升高与术后肌钙蛋白 T 浓度的适度升高相关，但与术后心血管并发症或院内死亡率无关。脉压并不比收缩压更好地预测这些结果。
