Period-dependent Associations between Hypotension during and for Four Days after Noncardiac Surgery and a Composite of Myocardial Infarction and Death
Period-dependent Associations between Hypotension during and for Four Days after Noncardiac Surgery and a Composite of Myocardial Infarction and Death
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DOI：
10.1097/aln.0000000000001985
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发表时间：
2018-02-01
期刊：
影响因子：
8.8
通讯作者：
Devereaux, P. J.
中科院分区：
文献类型：
--
作者：
Sessler, Daniel I.;Meyhoff, Christian S.;Devereaux, P. J.
背景：术中和术后低血压对围手术期发病率的相对影响尚不清楚。我们确定了低血压与30天心肌梗死和死亡的复合物之间的相关性，分为三个阶段：（1）术中，（2）手术剩余天数，（3）术后最初4天。方法：这是POISE-2的一项子研究，该研究是一项10，010例患者的随机因素试验，研究阿司匹林和可乐定预防心肌梗死。具有临床意义的低血压定义为收缩压低于90 mmHg，需要治疗。低血压分钟数是术中和手术剩余天数的暴露变量，而低血压状态被视为术后第1 - 4天的二元变量。我们估计的平均相对影响低血压的复合使用不同的效果广义估计模型，调整低血压在早期periods.Results：在9,765例患者中，42%经历了低血压，590（6.0%）有梗死，116（1.2%）手术后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估计平均相对效应为1.08（98.3% CI，1.03，1.12; P < 0.001）。在手术的剩余时间，低血压持续时间每增加10分钟，比值比为1.03（98.3% CI，1.01，1.05; P < 0.001）。平均相对效应比值比为2.83（98.3%CI，1.26，6.35; P = 0.002）。结论：临床上重要的心绞痛--一种潜在的可改变的心绞痛--与三个围手术期的心肌梗死和死亡的复合事件显著相关，即使在调整了先前的低血压之后。
Background: 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.Methods: 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.Results: 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.Conclusions: 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.