Postoperative myocardial ischemia in patients undergoing coronary artery bypass graft surgery. S.P.I. Research Group.
Postoperative myocardial ischemia in patients undergoing coronary artery bypass graft surgery. S.P.I. Research Group.
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接受冠状动脉搭桥手术的患者术后心肌缺血。
DOI：
10.1097/00000542-199103000-00013
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发表时间：
1991
期刊：
影响因子：
8.8
通讯作者：
Mangano,DT
中科院分区：
文献类型：
--
作者：
Smith,RC;Leung,JM;Mangano,DT
冠状动脉旁路移植术（CABG）手术后的心脏病发病率和死亡率仍然是一个重大问题。为了确定CABG术后心肌缺血的患病率、特征和预后重要性，作者使用双导联心电图（ECG）对50例患者进行了连续10天的围手术期监测。与缺血一致的ECG变化定义为可逆性ST段压低1 mm或更大，或从基线升高2 mm或更大，持续至少1 min。根据位置变化和时间漂移调整基线。所有事件均由两名独立的盲态研究者使用ECG监测仪（ECG复合波）进行验证。临床护理不受研究方案控制，临床医生不知道收集的研究数据。50例患者中有26例（52%）发生了207次围手术期缺血（3，409分钟缺血）。术后，48%的患者发生了缺血，而术前为12%，旁路手术前为10%。术后缺血在早期最常见（术后第0-2天[POD]; 38%的患者），在血运重建后的前2小时达到峰值，在术后晚期较不常见（POD 3-7; 24%的患者）。几乎所有（120/122; 98%）术后发作（气管拔管后）均无症状：临床ECG监测仅检测到9/70（13%）早期发作。术后缺血似乎与心肌需氧量的急性变化无关：只有39%的术后发作之前心率增加超过20%。然而，心动过速在术后一周内持续存在（22-33%的心率大于100次/min），术后缺血（POD 0）患者更常发生心动过速（中位数43% vs. 12%; P <0.01）。手术当天发生了5例不良心脏结局;所有5例均发生在术后缺血之前，3例发生在搭桥术前的术中缺血，无一例发生在术前缺血之前。晚期术后缺血患者没有不良心脏结局。作者得出以下结论：1）术后缺血比术前或搭桥术前的术中缺血更普遍; 2）术后缺血的发生率在血运重建后不久达到峰值，在此期间缺血无症状，难以检测，并与不良心脏结局相关; 3）术后晚期缺血也是无症状的，但不太普遍，与住院期间不良心脏结局无关;和4）缺血和术后心率持续升高之间的关系可能存在，并需要进一步的研究。
Cardiac morbidity and mortality after coronary artery bypass graft (CABG) surgery continue to be significant problems. To determine the prevalence, characteristics, and prognostic importance of postoperative myocardial ischemia after CABG surgery, the authors monitored 50 patients continuously for 10 perioperative days with the use of two-lead electrocardiography (ECG). ECG changes consistent with ischemia were defined as a reversible ST depression of 1 mm or greater or an elevation of 2 mm or greater from baseline, lasting at least 1 min. Baseline was adjusted for positional changes and temporal drift. All episodes were verified, with the use of the ECG monitor printout (ECG complexes), by two independent blinded investigators. Clinical care was not controlled by study protocol, and clinicians were unaware of the research data collected. Twenty-six of 50 patients (52%) had 207 episodes of perioperative ischemia (3,409 ischemic minutes). Postoperatively, ischemia developed in 48% of patients, compared with 12% preoperatively and 10% intraoperatively before bypass. Postoperative ischemia was most common in the early period (postoperative days [PODs] 0-2; 38% of patients), peaking during the first 2 h after revascularization, and less common during the late postoperative period (PODs 3-7; 24% of patients). Almost all (120 of 122; 98%) postoperative episodes (after tracheal extubation) were asymptomatic: only 9 of 70 (13%) early episodes were detected by clinical ECG monitoring. Postoperative ischemia did not appear to be related to acute changes in myocardial oxygen demand: only 39% of the postoperative episodes were preceded by a greater than 20% increase in heart rate. However, tachycardia persisted throughout the postoperative week (22-33% of all heart rates greater than 100 beats per min), and patients with postoperative ischemia (POD 0) more frequently had tachycardia (median 43% vs. 12% of the time; P less than 0.01). Five adverse cardiac outcomes occurred on the day of surgery; all five were preceded by postoperative ischemia, three by intraoperative ischemia before bypass, and none by preoperative ischemia. Patients with late postoperative ischemia did not have an adverse cardiac outcome. The authors conclude the following: 1) ischemia is more prevalent postoperatively than preoperatively or intraoperatively before bypass; 2) the incidence of postoperative ischemia peaks shortly after revascularization, during which time it is symptomatically silent, difficult to detect, and related to adverse cardiac outcome; 3) late postoperative ischemia also is silent, but it is less prevalent and not associated with in-hospital adverse cardiac outcome; and 4) a relationship between ischemia and persistently elevated postoperative heart rate may exist and warrants additional investigation.