圍手術期精細心率調控對心肌保護效應的系統評價_《中國循證醫學雜志》

作者：

米克熱依賽買提 ,  鄭宏

新疆醫科大學第一附屬醫院麻醉科（烏魯木齊?830054）;

關鍵詞：

β受體阻滯劑圍手術期心率心肌保護 Meta分析系統評價

DOI：

10.7507/1672-2531.20110097

視頻：

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目的　系統評價圍手術期精細心率調控與β受體阻滯劑發揮心肌保護效應的相關性，探討圍手術期心肌保護的有效措施。
方法　計算機檢索PubMed、Ovid、EMbase、MEDLINE、Cochrane圖書館對照試驗資料庫、Highwire數據庫、CNKI、CBM和VIP數據庫（檢索時間截至2010年12月），收集國內外1999～2009年關于評價非心臟手術圍手術期β受體阻滯劑心肌保護效應的臨床隨機對照試驗（RCT），按照納入與排除標準進行資料提取和質量評價后，采用RevMan 5.0軟件進行Meta分析。
結果　共納入13個RCT，共計11 590例患者。Meta分析結果顯示：非心臟手術患者圍手術期應用β受體阻滯劑能減少圍手術期心臟不良事件的發生率［OR=0.64，95%CI（0.50，0.80），P=0.000 1］，但納入研究間具有明顯的異質性（I2=57%）；亞組分析結果顯示，心率 lt;100次/分組，β受體阻滯劑能明顯減少圍手術期心臟不良事件的發生率［OR=0.37，95%CI（0.26，0.52），P lt;0.000 01］，而對于心率 gt;100次/分組，β受體阻滯劑減少圍手術期心臟不良事件發生率的作用并不明顯［OR=1.13，95%CI（0.81，1.59），P=0.48］。
結論　本系統評價結果顯示，應用β受體阻滯劑對圍手術期患者實施心肌保護是必須的，但心率的調控不能僅靠β受體阻滯劑實現，而應該是麻醉深度、容量治療、聯合用藥及非處理因素等嚴格控制的共同結果。

引用本文： 米克熱依賽買提,鄭宏. 圍手術期精細心率調控對心肌保護效應的系統評價. 中國循證醫學雜志, 2011, 11(5): 545-553. doi: 10.7507/1672-2531.20110097 復制

1.	2 Bonow RO, Carabello BA, Chatterjee K, et al . ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol , 2006, 48: e1-e148.
2.	朱煒華, 萬林駿. 非心臟手術圍手術期β受體阻滯劑應用進展. 醫學綜述, 2010, 16(5): 731-734.
3.	Zuanetti G, Mantini L, Hernández-Bernal F, et al . Relevance of heart rate as a prognostic factor in patients with acute myocardial infarction: insights from the GISSI-2 study. Eur Heart J , 1998, 19 Suppl F: F19-26.
4.	吳學思. 心率在心血管疾病中的意義. 中華內科雜志, 2006, 45(7): 601-603.
5.	王春梅, 吳學思, 韓智紅. 入院時心率對急性心肌梗死患者住院死亡率的影響. 中華心血管病雜志, 2008, 36(7): 594-597.
6.	Higgins JPT, Altman DG (editors). Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, greens (editors). Cochrane handbook for systematic reviews of interventions versions 5.0.1 (updated September 2008). The Cochrane Collaboration, 2008.
7.	Zaugg M, Bestmann L, Wacker J, et al . Adrenergic receptor genotype but not perioperative bisoprolol therapy may determine cardiovascular outcome in at-risk patients undergoing surgery with spinal block: the Swiss Beta Blocker in Spinal Anesthesia (BBSA) study: a double-blinded, placebo-controlled, multicenter trial with 1-year follow-up. Anesthesiology , 2007, 107(1): 33-44.
8.	van Klei WA, Bryson GL, Yang H, et al . Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology , 2009, 111(4): 717-724.
9.	Poldermans D, Boersma E, Bax JJ, et al . Bisoprolol reduces cardiac death and myocardial infarction in high-risk patients as long as 2 years after successful major vascular surgery. Eur Heart J , 2001, 22(15): 1353-1358.
10.	Raby KE, Brull SJ, Timimi F, et al . The effect of heart rate control on myocardial ischemia among high-risk patients after vascular surgery. Anesth Analg , 1999, 88(3): 477-482.
11.	Zaugg M, Tagliente T, Lucchinetti E, et al . Beneficial effects from beta-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology , 1999, 91(6): 1674-1686.
12.	Brady AR, Gibbs JS, Greenhalgh RM, et al . Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. J Vasc Surg , 2005, 41(4): 602-609.
13.	Yang H, Raymer K, Butler R, et al . The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J , 2006, 152(5): 983-990.
14.	POISE Study Group, Devereaux PJ, Yang H, et al . Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet , 2008, 371(9627): 1839-1847.
15.	賴仁純, 許梅曦, 黃文起, 等. 美托洛爾對老年食管癌患者圍手術期心臟功能的保護作用. 癌癥, 2006, 25(5): 609-613.
16.	劉瑤, 黃昌林, 賀民, 等. 圍手術期美托洛爾對老年非心臟手術病人血流動力學及心肌缺血的影響. 中南大學學報(醫學版), 2006, 31(2): 2491.
17.	Urban MK, Markowitz SM, Gordon MA, et al . Postoperative prophylactic administration of beta-adrenergic blockers in patients at risk for myocardial ischemia. Anesth Analg , 2000; 90(6): 1257-1261.
18.	Bayliff CD, Massel DR, Inculet RI, et al . Propranolol for the prevention of postoperative arrhythmias in general thoracic surgery. Ann Thorac Surg , 1999, 67(1): 182-186.
19.	Juul AB, Wetterslev J, Gluud C, et al . Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ , 2006, 332(7556): 1482.
20.	Schouten O, Bax JJ, Dunkelgrun M, et al . Pro: Beta-blockers are indicated for patients at risk for cardiac complications undergoing noncardiac surgery. Anesth Analg , 2007, 104(1): 8-10.
21.	Sipahi I, Tuzcu EM, Wolski KE, et al . Beta-blockers and progression of coronary atherosclerosis: pooled analysis of 4 intravascular ultrasonography trials. Ann Intern Med , 2007, 147(1): 10-18.
22.	Lemaitre RN, Heckbert SR, Sotoodehnia N, et al . beta1- and beta2-adrenergic receptor gene variation, beta-blocker use and risk of myocardial infarction and stroke. Am J Hypertens , 2008, 21(3): 290-296.
23.	Fleisher LA, Beckman JA, Brown KA, ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology. J Am Coll Cardiol , 2006, 47(11): 2343-2355.
24.	Kaafarani HM, Atluri PV, Thornby J, et al . beta-Blockade in noncardiac surgery: outcome at all levels of cardiac risk. Arch Surg , 2008, 143(10):940-944.
25.	Redelmeier D, Scales D, Kopp A. Beta blockers for elective surgery in elderly patients: population based, retrospective cohort study. BMJ , 2005, 331(7522): 932.
26.	Lindenauer PK, Pekow P, Wang K, et al . Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med , 2005, 353(4): 349-361.
27.	Bangalore S, Wetterslev J, Pranesh S, et al . Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. Lancet , 2008, 372(9654): 1962-1976.
28.	Devereaux PJ, Goldman L, Yusuf S, et al . Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review. CMAJ , 2005, 173(7): 779-788.
29.	Wallace A, Layug B, Tateo I, et al . Prophylactic atenolol reduces postoperative myocardial ischemia. McSPI Research Group. Anesthesiology , 1998, 88(1): 7-17.
30.	Chopra V, Eagle KA. Perioperative beta-blockers for cardiac risk reduction: time for clarity. JAMA , 2010, 303(6): 551-552.
31.	Kadoi Y, Saito S. Possible indications of beta-blockers in the perioperative period other than prevention of cardiac ischemia. J Anesth , 2010, 24(1): 81-95.
32.	Stephens S. State of the science: beta-blockers and reduction of perioperative cardiac events. Crit Care Nurs Clin North Am , 2010, 22(2): 209-215.

1. 2 Bonow RO, Carabello BA, Chatterjee K, et al . ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol , 2006, 48: e1-e148.
2. 朱煒華, 萬林駿. 非心臟手術圍手術期β受體阻滯劑應用進展. 醫學綜述, 2010, 16(5): 731-734.
3. Zuanetti G, Mantini L, Hernández-Bernal F, et al . Relevance of heart rate as a prognostic factor in patients with acute myocardial infarction: insights from the GISSI-2 study. Eur Heart J , 1998, 19 Suppl F: F19-26.
4. 吳學思. 心率在心血管疾病中的意義. 中華內科雜志, 2006, 45(7): 601-603.
5. 王春梅, 吳學思, 韓智紅. 入院時心率對急性心肌梗死患者住院死亡率的影響. 中華心血管病雜志, 2008, 36(7): 594-597.
6. Higgins JPT, Altman DG (editors). Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, greens (editors). Cochrane handbook for systematic reviews of interventions versions 5.0.1 (updated September 2008). The Cochrane Collaboration, 2008.
7. Zaugg M, Bestmann L, Wacker J, et al . Adrenergic receptor genotype but not perioperative bisoprolol therapy may determine cardiovascular outcome in at-risk patients undergoing surgery with spinal block: the Swiss Beta Blocker in Spinal Anesthesia (BBSA) study: a double-blinded, placebo-controlled, multicenter trial with 1-year follow-up. Anesthesiology , 2007, 107(1): 33-44.
8. van Klei WA, Bryson GL, Yang H, et al . Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology , 2009, 111(4): 717-724.
9. Poldermans D, Boersma E, Bax JJ, et al . Bisoprolol reduces cardiac death and myocardial infarction in high-risk patients as long as 2 years after successful major vascular surgery. Eur Heart J , 2001, 22(15): 1353-1358.
10. Raby KE, Brull SJ, Timimi F, et al . The effect of heart rate control on myocardial ischemia among high-risk patients after vascular surgery. Anesth Analg , 1999, 88(3): 477-482.
11. Zaugg M, Tagliente T, Lucchinetti E, et al . Beneficial effects from beta-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology , 1999, 91(6): 1674-1686.
12. Brady AR, Gibbs JS, Greenhalgh RM, et al . Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. J Vasc Surg , 2005, 41(4): 602-609.
13. Yang H, Raymer K, Butler R, et al . The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J , 2006, 152(5): 983-990.
14. POISE Study Group, Devereaux PJ, Yang H, et al . Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet , 2008, 371(9627): 1839-1847.
15. 賴仁純, 許梅曦, 黃文起, 等. 美托洛爾對老年食管癌患者圍手術期心臟功能的保護作用. 癌癥, 2006, 25(5): 609-613.
16. 劉瑤, 黃昌林, 賀民, 等. 圍手術期美托洛爾對老年非心臟手術病人血流動力學及心肌缺血的影響. 中南大學學報(醫學版), 2006, 31(2): 2491.
17. Urban MK, Markowitz SM, Gordon MA, et al . Postoperative prophylactic administration of beta-adrenergic blockers in patients at risk for myocardial ischemia. Anesth Analg , 2000; 90(6): 1257-1261.
18. Bayliff CD, Massel DR, Inculet RI, et al . Propranolol for the prevention of postoperative arrhythmias in general thoracic surgery. Ann Thorac Surg , 1999, 67(1): 182-186.
19. Juul AB, Wetterslev J, Gluud C, et al . Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ , 2006, 332(7556): 1482.
20. Schouten O, Bax JJ, Dunkelgrun M, et al . Pro: Beta-blockers are indicated for patients at risk for cardiac complications undergoing noncardiac surgery. Anesth Analg , 2007, 104(1): 8-10.
21. Sipahi I, Tuzcu EM, Wolski KE, et al . Beta-blockers and progression of coronary atherosclerosis: pooled analysis of 4 intravascular ultrasonography trials. Ann Intern Med , 2007, 147(1): 10-18.
22. Lemaitre RN, Heckbert SR, Sotoodehnia N, et al . beta1- and beta2-adrenergic receptor gene variation, beta-blocker use and risk of myocardial infarction and stroke. Am J Hypertens , 2008, 21(3): 290-296.
23. Fleisher LA, Beckman JA, Brown KA, ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology. J Am Coll Cardiol , 2006, 47(11): 2343-2355.
24. Kaafarani HM, Atluri PV, Thornby J, et al . beta-Blockade in noncardiac surgery: outcome at all levels of cardiac risk. Arch Surg , 2008, 143(10):940-944.
25. Redelmeier D, Scales D, Kopp A. Beta blockers for elective surgery in elderly patients: population based, retrospective cohort study. BMJ , 2005, 331(7522): 932.
26. Lindenauer PK, Pekow P, Wang K, et al . Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med , 2005, 353(4): 349-361.
27. Bangalore S, Wetterslev J, Pranesh S, et al . Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. Lancet , 2008, 372(9654): 1962-1976.
28. Devereaux PJ, Goldman L, Yusuf S, et al . Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review. CMAJ , 2005, 173(7): 779-788.
29. Wallace A, Layug B, Tateo I, et al . Prophylactic atenolol reduces postoperative myocardial ischemia. McSPI Research Group. Anesthesiology , 1998, 88(1): 7-17.
30. Chopra V, Eagle KA. Perioperative beta-blockers for cardiac risk reduction: time for clarity. JAMA , 2010, 303(6): 551-552.
31. Kadoi Y, Saito S. Possible indications of beta-blockers in the perioperative period other than prevention of cardiac ischemia. J Anesth , 2010, 24(1): 81-95.
32. Stephens S. State of the science: beta-blockers and reduction of perioperative cardiac events. Crit Care Nurs Clin North Am , 2010, 22(2): 209-215.

《中國循證醫學雜志》

圍手術期精細心率調控對心肌保護效應的系統評價

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《中國循證醫學雜志》

圍手術期精細心率調控對心肌保護效應的系統評價

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