中华医学杂志
中華醫學雜誌
중화의학잡지
National Medical Journal of China
2011年
15期
1016-1021
,共6页
陈伟%张健群%甘辉立%王胜洵%孔睛宇%郑斯宏%伯平%黄国晖
陳偉%張健群%甘輝立%王勝洵%孔睛宇%鄭斯宏%伯平%黃國暉
진위%장건군%감휘립%왕성순%공정우%정사굉%백평%황국휘
冠心动脉疾病%手术期间%他汀类药物
冠心動脈疾病%手術期間%他汀類藥物
관심동맥질병%수술기간%타정류약물
Coronary disease%Intraoperative period%Statins
目的 评价冠状动脉左主干狭窄(LMS)行冠状动脉搭桥术(CABG)围术期及中长期疗效,并分析术前应用他汀类药物对围术期疗效的影响.方法 回顾性分析1998年1月至2008年3月北京安贞医院收治626例LMS行CABG围术期疗效资料及中长期随访结果,按患者在入院前是否服用他汀类药物(持续2周以上)将LMS患者分为服用他汀类药物组(A组,n=322例),未服用他汀类药物组(B组,n=304例);根据手术性质分为两组:非急诊手术组(n=456例),急症手术组(n=170例).结果 住院死亡27例(4.31%),其中A组住院死亡6例(1.90%);B组住院死亡21例(6.91%),x2检验x2=9.642,P=0.002.非急诊手术组住院死亡9例(1.97%);急诊手术组住院死亡18例(10.6%),x2检验,x2=22.267,P=0.000.术前应用他汀类药物可降低围术期全因病死率(1.90%vs 6.91%,P=0.002)、房性心律失常的发生率(14.69%vs19.61%,x2=5.780,P=0.016)、致残性中风的发生率(2.50%vs4.58%,x2=3.94,P=0.047).围术期生存599例患者中,完整随访565例,随访率为94.3%,随访时间1～98(56±26)个月,总随访时间为2610患者年,随访期间发生心脏事件为29例次(4.63%),其中死亡为12例,再发心肌梗死事件17例.43例(7.18%)心绞痛复发,余者心绞痛症状均消失.单因素分析发现急诊手术、术前C反应蛋白增高、肌钙蛋白增高、LMS复杂病变(累及左主干分叉)、术前需要IABP支持、术前有心跳骤停史、既往心梗史、术前未应用他汀类药物为早期死亡危险因子;而既往心梗史、LMS复杂病变(累及左主干分叉)、术前需要IABP支持、术前有心跳骤停史、术前未应用他汀类药物为晚期死亡的危险因子.多因素Binary Logistic回归分析发现,术前C反应蛋白和肌钙蛋白增高、急诊手术、术前需要IABP支持、术前未应用他汀类药物是早期死亡的独立危险因子;而术前需要IABP支持、术前未应用他汀类药物、复杂病变(累及左主干分叉)、术前心脏骤停史为晚期死亡的独立危险因子.常规体外循环下CABG、OPCAB是手术风险差异无统计学意义.结论 LMS病变行CABG手术病死率相对较高,但术前应用他汀类药物对LMS病变的CABG可有效提高围术期生存率、降低不良事件发生率.
目的 評價冠狀動脈左主榦狹窄(LMS)行冠狀動脈搭橋術(CABG)圍術期及中長期療效,併分析術前應用他汀類藥物對圍術期療效的影響.方法 迴顧性分析1998年1月至2008年3月北京安貞醫院收治626例LMS行CABG圍術期療效資料及中長期隨訪結果,按患者在入院前是否服用他汀類藥物(持續2週以上)將LMS患者分為服用他汀類藥物組(A組,n=322例),未服用他汀類藥物組(B組,n=304例);根據手術性質分為兩組:非急診手術組(n=456例),急癥手術組(n=170例).結果 住院死亡27例(4.31%),其中A組住院死亡6例(1.90%);B組住院死亡21例(6.91%),x2檢驗x2=9.642,P=0.002.非急診手術組住院死亡9例(1.97%);急診手術組住院死亡18例(10.6%),x2檢驗,x2=22.267,P=0.000.術前應用他汀類藥物可降低圍術期全因病死率(1.90%vs 6.91%,P=0.002)、房性心律失常的髮生率(14.69%vs19.61%,x2=5.780,P=0.016)、緻殘性中風的髮生率(2.50%vs4.58%,x2=3.94,P=0.047).圍術期生存599例患者中,完整隨訪565例,隨訪率為94.3%,隨訪時間1～98(56±26)箇月,總隨訪時間為2610患者年,隨訪期間髮生心髒事件為29例次(4.63%),其中死亡為12例,再髮心肌梗死事件17例.43例(7.18%)心絞痛複髮,餘者心絞痛癥狀均消失.單因素分析髮現急診手術、術前C反應蛋白增高、肌鈣蛋白增高、LMS複雜病變(纍及左主榦分扠)、術前需要IABP支持、術前有心跳驟停史、既往心梗史、術前未應用他汀類藥物為早期死亡危險因子;而既往心梗史、LMS複雜病變(纍及左主榦分扠)、術前需要IABP支持、術前有心跳驟停史、術前未應用他汀類藥物為晚期死亡的危險因子.多因素Binary Logistic迴歸分析髮現,術前C反應蛋白和肌鈣蛋白增高、急診手術、術前需要IABP支持、術前未應用他汀類藥物是早期死亡的獨立危險因子;而術前需要IABP支持、術前未應用他汀類藥物、複雜病變(纍及左主榦分扠)、術前心髒驟停史為晚期死亡的獨立危險因子.常規體外循環下CABG、OPCAB是手術風險差異無統計學意義.結論 LMS病變行CABG手術病死率相對較高,但術前應用他汀類藥物對LMS病變的CABG可有效提高圍術期生存率、降低不良事件髮生率.
목적 평개관상동맥좌주간협착(LMS)행관상동맥탑교술(CABG)위술기급중장기료효,병분석술전응용타정류약물대위술기료효적영향.방법 회고성분석1998년1월지2008년3월북경안정의원수치626례LMS행CABG위술기료효자료급중장기수방결과,안환자재입원전시부복용타정류약물(지속2주이상)장LMS환자분위복용타정류약물조(A조,n=322례),미복용타정류약물조(B조,n=304례);근거수술성질분위량조:비급진수술조(n=456례),급증수술조(n=170례).결과 주원사망27례(4.31%),기중A조주원사망6례(1.90%);B조주원사망21례(6.91%),x2검험x2=9.642,P=0.002.비급진수술조주원사망9례(1.97%);급진수술조주원사망18례(10.6%),x2검험,x2=22.267,P=0.000.술전응용타정류약물가강저위술기전인병사솔(1.90%vs 6.91%,P=0.002)、방성심률실상적발생솔(14.69%vs19.61%,x2=5.780,P=0.016)、치잔성중풍적발생솔(2.50%vs4.58%,x2=3.94,P=0.047).위술기생존599례환자중,완정수방565례,수방솔위94.3%,수방시간1～98(56±26)개월,총수방시간위2610환자년,수방기간발생심장사건위29례차(4.63%),기중사망위12례,재발심기경사사건17례.43례(7.18%)심교통복발,여자심교통증상균소실.단인소분석발현급진수술、술전C반응단백증고、기개단백증고、LMS복잡병변(루급좌주간분차)、술전수요IABP지지、술전유심도취정사、기왕심경사、술전미응용타정류약물위조기사망위험인자;이기왕심경사、LMS복잡병변(루급좌주간분차)、술전수요IABP지지、술전유심도취정사、술전미응용타정류약물위만기사망적위험인자.다인소Binary Logistic회귀분석발현,술전C반응단백화기개단백증고、급진수술、술전수요IABP지지、술전미응용타정류약물시조기사망적독립위험인자;이술전수요IABP지지、술전미응용타정류약물、복잡병변(루급좌주간분차)、술전심장취정사위만기사망적독립위험인자.상규체외순배하CABG、OPCAB시수술풍험차이무통계학의의.결론 LMS병변행CABG수술병사솔상대교고,단술전응용타정류약물대LMS병변적CABG가유효제고위술기생존솔、강저불량사건발생솔.
Objective To evaluate the early, middle and long-term clinical outcomes of coronary artery bypass grafting (CABG) for a special subset of left main coronary stenosis (LMS). Methods A total of 626 LMS patients, recruited at our hospital between January 1998 and March 2008, were classified them into the statin therapy group ( Group A, n = 322) or the non-statin therapy group ( Group B, n = 304 )according to whether or not taking statins pre-operatively. Then their clinical data were retrospectively analyzed. Results The inhospital mortality was 4. 31% ( n = 27 ). And the mortality was 1.90% ( n = 6) for Group A and 6. 91% for Group B ( n = 21 ) (x2 test, x2 = 9. 642, P = 0. 002 ). Preoperative statin therapy could lower the all-cause mortality rate ( 1.90% vs 6. 91%, P = 0. 002), the prevalence of new atrial fibrillation or flutter ( 14. 69% vs 19. 61%, P = 0. 016, x2 = 5. 780 ) and disabling stroke ( 2. 50% vs4. 58%, P =0. 047, x2 =3.94). Among 599 CABG survivors, 565 cases (94. 3% ) were actually followed up with a mean duration of 55.5 ±26. 1 months (range:2 -98). During the follow-up period, there were 29(4.63%) cardiac events, including 12 deaths and 17 myocardial infarctions. There were 43 (7. 18% ) cases with relapsing angina pectoris. The univariate analysis showed that emergency procedure, abnormal C-reactive protein (CRP), abnormal troponin I (TnI), complicated LMS pathology, preoperative IABP (intra-aortic balloon pump) support, preoperative cardiac arrest, preoperative history of myocardium infarction and no preoperative statin therapy were the risk factors for perioperative death while complicated LMS pathology,preoperative IABP support, preoperative cardiac arrest, preoperative myocardium infarction and no preoperative statin therapy were the risk factor for late cardiac events. The multivariate binary logistic regression showed that emergency procedure, preoperative IABP support, no preoperative statin therapy and preoperative IABP support were independent predictors for peri-operative death. And preoperative IABP support, preoperative cardiac arrest, no preoperative statin therapy and complicated LMS pathology were independent predictors for late cardiac events. There was no statistical significance in inhospital mortality between on pump CABG and OPCAB (off pump coronary artery bypass). Conclusion The CABG procedure for LMS carries a relative high mortality. However preoperative statin therapy may offer such protective effects as lowering the all-cause mortality rate and reducing the prevalence of new atrial fibrillation or flutter and disabling stroke.
