代谢手术与既往心肌梗死和重度肥胖患者主要不良心血管结局的关联：一项全国性队列研究。

Association of Metabolic Surgery With Major Adverse Cardiovascular Outcomes in Patients With Previous Myocardial Infarction and Severe Obesity: A Nationwide Cohort Study.

机构信息

Division of Surgery (E.N., R.M.), Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.

Department of Surgery, Faculty of Medicine and Health, Örebro University, Sweden (E.S., J.O.).

出版信息

Circulation. 2021 Apr 13;143(15):1458-1467. doi: 10.1161/CIRCULATIONAHA.120.048585. Epub 2020 Oct 26.

DOI:10.1161/CIRCULATIONAHA.120.048585

PMID:33103469

Abstract

BACKGROUND

The number of patients with myocardial infarction and severe obesity is increasing and there is a lack of evidence how these patients should be treated. The aim of this study was to investigate the association between metabolic surgery (Roux-en-Y gastric bypass and sleeve gastrectomy) and major adverse cardiovascular events in patients with previous myocardial infarction (MI) and severe obesity.

METHODS

Of 566 patients with previous MI registered in the SWEDEHEART registry (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) undergoing metabolic surgery and registered in the nationwide Scandinavian Obesity Surgery Registry, 509 patients (Roux-en-Y gastric bypass n=465; sleeve gastrectomy n=44) could be matched 1:1 to a control with MI from SWEDEHEART, but no subsequent metabolic surgery regarding sex, age (±3 years), year of MI (±3 years), and body mass index (±3). The 2 groups were well matched, except for a lower proportion of reduced ejection fraction after MI (7% versus 12%), previous heart failure (10% versus 19%), atrial fibrillation (6% versus 10%), and chronic obstructive pulmonary disease (4% versus 7%) in patients undergoing metabolic surgery.

RESULTS

The median (interquartile range) follow-up time was 4.6 (2.7-7.1) years. The 8-year cumulative probability of major adverse cardiovascular events was lower in patients undergoing metabolic surgery (18.7% [95% CI, 15.9-21.5%] versus 36.2% [33.2-39.3%], adjusted hazard ratio, 0.44 [95% CI, 0.32-0.61]). Patients undergoing metabolic surgery had also a lower risk of death (adjusted HR, 0.45 [95% CI, 0.29-0.70]; MI, 0.24 [0.14-0.41]) and new onset heart failure, but there were no significant differences regarding stroke (0.91 [0.38-2.20]) and new onset atrial fibrillation (0.56 [0.31-1.01]).

CONCLUSIONS

In severely obese patients with previous MI, metabolic surgery is associated with a low risk for serious complications, lower risk of major adverse cardiovascular events, death, new MI, and new onset heart failure. These findings need to be confirmed in a randomized, controlled trial.

摘要

背景

心肌梗死和严重肥胖患者的数量不断增加，而对于这些患者应如何治疗，目前还缺乏相关证据。本研究旨在探讨代谢手术（胃旁路手术和袖状胃切除术）与既往心肌梗死（MI）和严重肥胖患者的主要不良心血管事件之间的关系。

方法

在 SWEDEHEART 注册中心（瑞典基于推荐治疗的心脏病循证治疗增强和发展网络系统）登记的 566 例既往有 MI 并接受代谢手术的患者中，有 509 例（胃旁路手术 n=465；袖状胃切除术 n=44）可与 SWEDEHEART 中的 MI 对照组进行 1:1 匹配，两组的性别、年龄（±3 岁）、MI 发生年份（±3 年）和体重指数（±3）相匹配。两组除了 MI 后射血分数降低的比例较低（7%对 12%）、既往心力衰竭（10%对 19%）、心房颤动（6%对 10%）和慢性阻塞性肺疾病（4%对 7%）外，其余情况均匹配良好。

结果

中位（四分位间距）随访时间为 4.6（2.7-7.1）年。接受代谢手术的患者 8 年主要不良心血管事件累积发生率较低（18.7%[95%CI，15.9-21.5%]对 36.2%[33.2-39.3%]，调整后的危险比，0.44[95%CI，0.32-0.61]）。接受代谢手术的患者死亡风险也较低（调整后的 HR，0.45[95%CI，0.29-0.70]；心肌梗死，0.24[0.14-0.41]）和新发心力衰竭，但中风（0.91[0.38-2.20]）和新发心房颤动（0.56[0.31-1.01]）的风险差异无统计学意义。