高龄冠心病患者行非心脏手术的围术期心脏事件危险因素分析

doi:10.3881/j.issn.1000-503X.2015.05.009

Acta Academiae Medicinae Sinica

Acta Academiae Medicinae Sinica ›› 2015, Vol. 37 ›› Issue (5): 541-548.doi: 10.3881/j.issn.1000-503X.2015.05.009

• Orginal Article • Previous Articles Next Articles

Risk Factors of Perioperative Cardiac Events in Elderly Patients with Coronary Heart Disease Undergoing Non-cardiac Surgery

Zi-jia LIU¹, Li XU¹(), Chun-hua YU¹, Hong ZHENG², Shang-long YAO³, Ling PEI⁴, Li SUN⁵, Jing-mei JIANG⁶, Yu-guang HUANG¹

¹Department of Anesthesiology,PUMC Hospital,CAMS and PUMC,Beijing 100730,China
²Department of Anesthesiology,the First Teaching Hospital of Xinjiang Medical University,Urumqi 830054,China
³Department of Anesthesiology,Union Hospital,Tongji Medical College,Huazhong University of Science and Technology,Wuhan 430022,China
⁴ Department of Anesthesiology,the First Hospital of China Medical University,Shenyang 110001,China
⁵Department of Anesthesiology,Cancer Hospital,CAMS and PUMC,Beijing100021,China
⁶ Department of Epidemiology and Statistics,Institute of Basic Medicine,CAMS and PUMC,Beijing 100005,China

Received:2015-03-10 Online:2015-10-15 Published:2015-10-31
Supported by:
Supported by the Public Welfare Scientific Research Project,the Ministry of Health(200802030)

Abstract

Abstract:

Objective To identify the incidence and risk factors of perioperative major adverse cardiac events(MACE)in elderly patients with coronary heart disease(CHD)undergoing non-cardiac surgery. Methods We prospectively analyzed the clinical data of 360 CHD patients who aged 75 years or older undergoing elective intermediate-to high-risk surgery in five medical centers across China from January 2008 to January 2010. The clinical variables included the 12-lead ECG and Troponin I levels after surgery. The combined outcome was defined as all the perioperative MACE in hospital. The risk factors of MACE and their indexes were analyzed with univariate analysis and multivariable logistic regression in SPSS software,together with a risk scoring and stratification system established. Results Perioperative MACE occurred in 11.94% of elderly CHD patients undergoing non-cardiac surgery. Seven independent risk factors of perioperative MACE for this population were identified,which included angina within 6 months(P=0.001),hypertension(P=0.014),preoperative haematocrit(HCT)<40%(P=0.050),serum creatinine(Scr)>150 mmol/L(P=0.014),ejection fraction(EF)<50%(P=0.019),intraoperative hyoxemia(P=0.019),and operative time>150 min(P=0.001). The risk indexes of these factors were 4,3,3,6,4,5,and 4,respectively. The rate of periopera- tive MACE increased significantly as the level of risk stratification elevated. Conclusions Elderly CHD patients undergoing non-cardiac surgery are at high risk of perioperative MACE. Angina within 6 months,hypertension,preoperative HCT<40%,Scr>150 mmol/L,EF<50%,intraoperative hyoxemia,and operative time>150 min can increase the risk of MACE. The risk scoring and stratification system based on the risk factor index can be a valuable parameter for assessing the perioperative cardiac risk of noncardiac surgery for elderly CHD patients.

Key words: elderly, coronary heart disease, non-cardiac surgery, cardiac events, risk factor

CLC Number:

R614.2

Zi-jia LIU, Li XU, Chun-hua YU, Hong ZHENG, Shang-long YAO, Ling PEI, Li SUN, Jing-mei JIANG, Yu-guang HUANG. Risk Factors of Perioperative Cardiac Events in Elderly Patients with Coronary Heart Disease Undergoing Non-cardiac Surgery[J].Acta Academiae Medicinae Sinica, 2015, 37(5): 541-548.

Figures/Tables 5

Fig 1

Table 1

Table 2

Comparison of preoperative tests of non-MACE and MACE groups"

分组 Group	术前心率 Preoperative heart rate(beats/min)	术前收缩压 Preoperative systolic pressure(mmHg)	术前舒张压 Preoperative diastolic pressure(mmHg)	术前体温 Preoperative temperature(℃)	功能能力 Functional capability <4 METs[n(%)]	术前血红蛋白 Preoperative hemoglobin(g/L)
无MACE(n=317) Non-MACE	75.9±10.7	137.6±18.4	77.6±10.1	36.5±0.4	65(20.5)	122.6±20.0
MACE(n=43)	78.5±14.8	136.8±17.7	77.3±11.8	36.5±0.3	10(23.3)	116.1±20.7
P	0.149	0.794	0.828	0.675	0.677	0.051
分组 Group	术前红细胞压积 Preoperative haematocrit [n(%)]	术前红细胞压积<40% Haematocrit<40% [n(%)]	术前血尿素氮 Preoperative blood urea nitrogen (mmol/L)	术前血肌酐 Preoperative serum creatinine (mmol/L)	血肌酐>150 mmol/L Serum creatinine >150 mmol/L [n(%)]	术前血糖 Preoperative blood glucose (mmol/L)
无MACE(n=317) Non-MACE	37.1±5.7	214(68.5)	6.0±2.1	79.1±27.5	6( 1.9)	5.8±1.5
MACE(n=43)	34.9±5.8	37(86.0)	6.0±2.8	88.8±36.2	5(11.6)	5.9±1.6
P	0.018	0.013	0.478	0.039	0.001	0.757
分组 Group	术前ECG异常 Preoperative ECG abnormality [n(%)]	心律失常 Arrhythmia [n(%)]	ST段压低/抬高 ST depression/ elevation [n(%)]	病理性Q波 Pathologic Q wave [n(%)]	射血分数 Ejection fraction [n(%)]	射血分数<50% Ejection fraction <50% [n(%)]
无MACE(n=317) Non-MACE	214(67.5)	111(35.0)	168(53.0)	29( 9.1)	63.7±6.6	10( 3.2)
MACE(n=43)	37(86.0)	17(39.5)	28(65.1)	5(11.3)	60.6±8.9	6(14.0)
P	0.012	0.561	0.134	0.602	0.007	0.001
分组 Group	左室舒张功能异常 Left ventricular diastolic dysfunction [n(%)]	室壁运动异常 Wall motion abnormality [n(%)]	室壁瘤 Ventricular aneurysm [n(%)]	肺动脉高压 Pulmonary arterial hypertension [n(%)]	ASA分级≥4 ASA classification≥4 [n(%)]
无MACE(n=317) Non-MACE	182(57.4)	34(10.7)	2(0.63)	19(6.0)	23(5.7)
MACE(n=43)	30(69.8)	8(18.6)	2(4.7)	4(9.3)	3(7.0)
P	0.122	0.131	0.018	0.405	0.947

Table 2

Table 3

Table 4

References 20

[1]	Scott IA,Shohag HA,Kam PC,et al.Preoperative cardiac evaluation and management of patients undergoing elective non-cardiac surgery[J]. Med J Aust,2013,199(10):667-673.
[2]	Fleisher LA,Beckman JA,Brown KA,et al.2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery:a report of the American College of Cardiology/American Heart Association task force on practice guidelines[J]. Circulation,2009,120(21):169-276.
[3]	Wu WC,Schifftner TL,Henderson WG,et al.Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery[J]. JAMA,2007,297(22):2481-2488.
[4]	Alcock RF,Kouzios D,Naoum C,et al.Perioperative myocardial necrosis in patients at high cardiovascular risk undergoing elective non-cardiac surgery[J]. Heart,2012,98(10):792-798.
[5]	Albaladejo P,Marret E,Samama CM,et al.Non-cardiac surgery in patients with coronary stents:the RECO study[J]. Heart,2011,97(19):1566-1572.
[6]	Lee TH,Marcantonio ER,Mangione CM,et al.Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery[J]. Circulation,1999,100(10):1043-1049.
[7]	Kheterpal S, O’Reilly M,Englesbe MJ, et al. Preoperative and intraoperative predictors of cardiac adverse events after general,vascular,and urological surgery[J]. Anesthesiology,2009,110(1):58-66.
[8]	Rao JY,Yeriswamy MC,Santhosh MJ,et al.A look into Lee’s score:peri-operative cardiovascular risk assessment in non-cardiac surgeries-usefulness of revised cardiac risk index[J]. Indian Heart J,2012,64(2):134-138.
[9]	Davis C,Tait G,Carroll J,et al.The revised cardiac risk index in the new millennium:a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients[J]. Can J Anaesth,2013,60(9):855-863.
[10]	Chobanian AV,Bakris GL,Black HR,et al.The Seventh Report of the Joint National Committee on Prevention,Detection,Evaluation,and Treatment of High Blood Pressure:the JNC 7 report[J]. JAMA,2003,289(19):2560-2572.
[11]	Hoeks SE,Scholte OP Reimer WJ,van Urk H, et al. Increase of 1-year mortality after perioperative beta-blocker withdrawal in endovascular and vascular surgery patients[J]. Eur J Vasc Endovasc Surg,2007,33(1):13-19.
[12]	Flynn BC,Vernick WJ,Ellis JE.β-Blockade in the perioperative management of the patient with cardiac disease undergoing non-cardiac surgery[J]. Br J Anaesth,2011,107(Suppl):i3-i15.
[13]	Ravensbergen NJ,Voute MT,Poldermans D.Safety of perioperative β-blocker use:how do β-blockers compare in terms of side effects[J]. Expert Opin Drug Saf,2011,10(4):545-558.
[14]	Khaled MM,Hani MT,Toby R,et al.Preoperative anaemia and postoperativeoutcomes in non-cardiac surgery:a retrospective cohort study[J]. Lancet,2011,378(9800):1396-1407.
[15]	Saito S,Takagi A,Kurokawa F,et al.Usefulness of tissue Doppler echocardiography to predict perioperative cardiac events in patients undergoingnoncardiac surgery[J]. Heart Vessels,2012,27(6):594-602.
[16]	Kertai MD,Boersma E,Bax JJ,et al.A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery[J]. Heart,2003,89(11):1327-1334.
[17]	Singh A,Antognini JF.Perioperative hypotension and myocardial ischemia:Diagnostic and therapeutic approaches[J]. Ann Card Anaesth,2011,14(2):127-132.
[18]	Gal J,Bogar L,Acsady G,et al.Cardiac risk reduction in non-cardiac surgery:the role of anaesthesia and monitoring techniques[J]. Eur J Anaesthesiol,2006,23(8):641-648.
[19]	Minto G,Scott MJ,Miller TE.Monitoring needs and goal-directed fluid therapy within an enhanced recovery program[J].Anesthesiol Clin,2015,33(1):35-49.
[20]	Glance LG,Kellermann AL,Hannan EL,et al.The impact of anesthesiologists on coronary artery bypass graft surgery outcomes[J]. Anesth Analg,2015,120(3):526-533.

分组 Group	年龄(岁) Age(year)	女性 Female [n(%)]	BMI (kg/m²)	汉族 Han nationality [n(%)]	吸烟史 History of smoking [n(%)]	吸烟状态 Smoking [n(%)]	冠脉重建史 Coronary reconstruction [n(%)]
无MACE(n=317) Non-MACE	78.2±3.3	134(42.3)	23.4±3.5	300( 83.3)	113(35.6)	50(15.7)	27(8.5)
MACE(n=43)	78.8±3.1	16(37.2)	23.4±3.9	43(100.0)	20(46.5)	12(27.9)	7(16.3)
P	0.227	0.528	0.977	0.120	0.166	0.048	0.102
分组 Group	心肌梗死史 Myocardial infarction [n(%)]	半年内心衰史 Heart failure within 6 months [n(%)]	半年内心绞痛史 Angina within 6 months [n(%)]	半年内不稳定心绞痛史 Unstable angina within 6 months [n(%)]	半年内心律失常史 Arrhythmia within 6 months [n(%)]		NYHA心功能分级≥Ⅲ NYHA cardiac classification≥Ⅲ [n(%)]
无MACE(n=317) Non-MACE	39(12.3)	2(0.6)	51(16.1)	33(10.4)	58(18.3)		62(19.6)
MACE(n=43)	9(20.9)	1(2.3)	16(37.2)	9(20.9)	10(23.3)		13(30.2)
P	0.118	0.251	0.001	0.044	0.436		0.106
分组 Group	高血压史 Hypertension [n(%)]	血压控制欠佳 Poor blood pressure control^a [n(%)]	大血管及外周血管病史 Large and peripheral vascular disease [n(%)]	脑血管病史 Cerebrovascular disease [n(%)]	糖尿病史 Diabetes [n(%)]	胰岛素控制的糖尿病史 Insulin control diabetes [n(%)]
无MACE(n=317) Non-MACE	178(56.2)	73(23.0)	31( 9.8)	48(15.1)	69(21.8)	23( 7.3)
MACE(n=43)	32(74.4)	9(20.9)	10(23.3)	12(27.9)	11(25.6)	5(11.6)
P	0.023	0.758	0.009	0.035	0.572	0.315

分组 Group	麻醉方式Anesthesia method[n(%)]			复合硬膜外镇痛 Compound epidural analgesia [n(%)]	吸入麻醉药 Inhaled anesthetic [n(%)]	复合笑气 Nitrous oxide [n(%)]	入室SpO₂<90% SpO₂<90% [n(%)]
分组 Group	全身麻醉 General anesthesia	椎管内麻醉 Intravertebral anesthesia	神经阻滞 Nerve block	复合硬膜外镇痛 Compound epidural analgesia [n(%)]	吸入麻醉药 Inhaled anesthetic [n(%)]	复合笑气 Nitrous oxide [n(%)]	入室SpO₂<90% SpO₂<90% [n(%)]
无MACE(n=317) Non-MACE	271(85.5)	27( 8.5)	19(6.0)	6(1.9)	190(60.0)	29( 9.1)	2(0.6)
MACE(n=43)	35(81.4)	5(11.6)	3(7.0)	2(4.7)	27( 62.7)	7(16.3)	3(7.0)
P	0.481	0.501	0.801	0.250	0.720	0.127	0.001
分组 Group	术中低血压 Intraoperative hypotension [n(%)]	术中高血压 Intraoperative hypertension [n(%)]	术中低氧 Intraoperative hyoxemia [n(%)]	术中总入量 Intraoperative fluid volume (ml)	术中晶体量 Intraoperative crystalloid solution(ml)	术中胶体量 Intraoperative colloidal solution(ml)	术中输血 Intraoperative transfusion [n(%)]
无MACE(n=317) Non-MACE	113(35.6)	171(53.9)	7(2.2)	1860.1± 975.7	1131.6±536.9	632.3±471.3	62(19.6)
MACE(n=43)	22(51.2)	27(62.8)	4(9.3)	2093.0±1004.9	1234.9±581.5	696.5±474.3	16(37.2)
P	0.049	0.274	0.011	0.144	0.242	0.403	0.009
分组 Group	输入红细胞 >4 U Red blood cells transfusion >4 U [n(%)]	输血量 >1000 ml Blood transfu- sion volume >1000 ml [n(%)]	出血量 >500 ml Blood loss >500 ml [n(%)]	手术时间 >150 min Operative time >150 min [n(%)]	预防深静脉血栓 Deep vein thrombosis prophylaxis [n(%)]	术后镇痛 Postoperative analgesia [n(%)]	术后24 h 引流量 >300 ml 24 h drainage >300 ml [n(%)]	术后48 h 引流量 >500 ml 48 h drainage >500 ml [n(%)]
无MACE(n=317) Non-MACE	7(2.2)	14(4.4)	30( 9.5)	122(38.5)	109(34.4)	51(16.1)	22(6.9)	11(3.5)
MACE(n=43)	1(2.3)	2(4.6)	10(23.3)	26(60.5)	19(44.2)	11(25.6)	4(9.3)	1(2.3)
P	0.943	0.919	0.007	0.006	0.208	0.122	0.574	0.695

变量 Variable	P	优势比 Odds ratio	95%可信区间 Confidence interval	危险指数 Risk index
半年内心绞痛史 Angina within 6 months	0.001	3.747	1.742-8.058	4
高血压史 Hypertension	0.014	2.701	1.218-5.992	3
术前红细胞压积<40% Preoperative haematocrit<40%	0.050	2.568	0.995-6.629	3
血肌酐>150 mmol/L Serum creatinine>150 mmol/L	0.014	5.700	1.419-22.893	6
射血分数<50% Ejection fraction<50%	0.019	4.316	1.269-14.678	4
术中低氧Intraoperative hyoxemia	0.019	5.288	1.320-21.189	5
手术时间>150 min Operative time>150 min	0.001	3.547	1.686-7.459	4

Acta Academiae Medicinae Sinica

Home

About Journal

Current Issue

Archive

Search

Contact Us

中文

Risk Factors of Perioperative Cardiac Events in Elderly Patients with Coronary Heart Disease Undergoing Non-cardiac Surgery

RichHTML

PDF (PC)

Like

Knowledge

Abstract

Cite this article

share this article

Figures/Tables 5

References 20

Related Articles 15

Metrics

Recommended 10

[1]	LI Chenyi,CHEN Jia,SHI Xiangfan. Associations of Non-alcoholic Fatty Liver Disease with Prevalence,Severity,and Prognosis of Coronary Heart Disease [J]. Acta Academiae Medicinae Sinica, 2019, 41(2): 156-161.
[2]	ZHENG Kesi,ZENG Yong,CHEN Cong,WU Yuanzhao,CHEN Bi,YING Wenbing,ZHENG Kewen. Risk Factors of Cervical Lymph Node Metastasis in Papillary Thyroid Microcarcinoma:An Analysis Based on Data from the Surveillance, Epidemiology and End Results Database [J]. Acta Academiae Medicinae Sinica, 2018, 40(6): 736-743.
[3]	FAN Danjun,LI Chenyi,CHEN Jin,YE Ziqing. Correlation between CYP2C19 Gene Polymorphism and Elderly Cerebral Infarction [J]. Acta Academiae Medicinae Sinica, 2018, 40(6): 765-768.
[4]	XIE Zhaoyun,CHEN Dong,CHEN Yingqiang,XIONG Yun,SUN Jing,YANG Zhongling. Logistic Regression Analysis of the Risk Factors for Multidrug-resistant Bacterial Infections in Chronic Rhinosinusitis [J]. Acta Academiae Medicinae Sinica, 2018, 40(6): 803-808.
[5]	CHEN Yun, LUO Zhi, ZENG Wei, LAI Feiya, CHEN Qiuhong, Lü Zhan, SONG Yongyan. Associations of the MicroRNA-143/145 Polymorphisms with Cardiovascular Risk Factors and the Severity of Coronary Heart Disease [J]. Acta Academiae Medicinae Sinica, 2018, 40(4): 510-518.
[6]	TIAN Jing, GUAN Wenxian, HE Jian, ZHOU Zhuping, FENG Min, WANG Hao, WANG Jun. Analysis of Related Factors in Elderly Patients with Strangulated Small Bowel Obstruction [J]. Acta Academiae Medicinae Sinica, 2018, 40(3): 321-327.
[7]	Li SU, Lan YOU, Hongping HUANG. Risk Factors of Intrauterine Adhesion after Hysteroscopic Resection of Endometrial Polyps [J]. Acta Academiae Medicinae Sinica, 2017, 39(6): 812-816.
[8]	Rui JIA, Xian XU, Xinqiu LIU, Bing WU, Weiwei MEN, Ningyu AN. Value of 3D Pseudo-continuous Arterial Spin Labeling Magnetic Resonance Perfusion Imaging in Evaluating Posterior Circulation Ischemia in the Elderly [J]. Acta Academiae Medicinae Sinica, 2017, 39(2): 272-279.
[9]	Kan WANG, Yiqing YIN. Risk Factors and Prognosis of Reintubation Following Surgeries under General Anesthesia [J]. Acta Academiae Medicinae Sinica, 2017, 39(1): 145-149.
[10]	Yong XIE, Yue-wu LIU, Meng-yi WANG, Wen-ze WANG, Hong-feng LIU, Xiao-yi LI, Wei-sheng GAO. Risk Factors of Lymphnode Metastasis in Patients with Thyroid Papillary Carcinoma Associated with Graves Disease [J]. Acta Academiae Medicinae Sinica, 2016, 38(5): 554-558.
[11]	Ling LAN, Yu-guan ZHANG, Jin WANG, Ya-hong GONG. Dilutional Hyponatremia during Hysteroscpic Surgery: Prevention and Treatment [J]. Acta Academiae Medicinae Sinica, 2016, 38(4): 470-474.
[12]	Hong LÜ, Ai-ling LIU, Ji LI, Dong WU, Yi-xiao ZHAO, Jia-ming QIAN. Clinical Characteristics of Ulcerative Colitis Complicated with Opportunistic Infections in Elderly Patients [J]. Acta Academiae Medicinae Sinica, 2016, 38(3): 288-293.
[13]	Li ZHU, Zhan LÜ, Yong-yan SONG. Advances in the Association between Apolipoprotein(a)Gene Polymorphisms and Coronary Heart Disease [J]. Acta Academiae Medicinae Sinica, 2015, 37(4): 482-488.
[14]	Xue-yan LI, Song YU, Qing-qing WU. Risk Factors and Perinatal Outcomes of Velamentous Umbilical Cord Insertion [J]. Acta Academiae Medicinae Sinica, 2015, 37(3): 355-357.
[15]	GAO He-li, BAI Chun-mei. Chemotherapy Risk Assessment for Elderly Patients [J]. Acta Academiae Medicinae Sinica, 2014, 36(5): 551-555.