围手术期精细心率调控对心肌保护效应的系统评价

Efficacy of Tight Heart Rate Control for Perioperative Myocardial Protection: A Systematic Review

目的系统评价围手术期精细心率调控与β受体阻滞剂发挥心肌保护效应的相关性,探讨围手术期心肌保护的有效措施。方法计算机检索PubMed、Ovid、EMbase、MEDLINE、Cochrane图书馆对照试验资料库、Highwire数据库、CNKI、CBM和VIP数据库(检索时间截至2010年12月),收集国内外1999～2009年关于评价非心脏手术围手术期β受体阻滞剂心肌保护效应的临床随机对照试验(RCT),按照纳入与排除标准进行资料提取和质量评价后,采用RevMan 5.0软件进行Meta分析。结果共纳入13个RCT,共计11 590例患者。Meta分析结果显示:非心脏手术患者围手术期应用β受体阻滞剂能减少围手术期心脏不良事件的发生率[OR=0.64,95%CI(0.50,0.80),P=0.0001],但纳入研究间具有明显的异质性(I2=57%);亚组分析结果显示,心率<100次/分组,β受体阻滞剂能明显减少围手术期心脏不良事件的发生率[OR=0.37,95%CI(0.26,0.52),P<0.00001],而对于心率>100次/分组,β受体阻滞剂减少围手术期心脏不良事件发生率的作用并不明显[OR=1.13,95%CI(0.81,1.59),P=0.48]。结论本系统评价结果显示,应用β受体阻滞剂对围手术期患者实施心肌保护是必须的,但心率的调控不能仅靠β受体阻滞剂实现,而应该是麻醉深度、容量治疗、联合用药及非处理因素等严格控制的共同结果。

Objective To systematically review the influence of tight heart rate（HR） control on the efficacy of perioperative β-blockade,and discuss the effective measures of perioperative myocardial protection.Methods We searched the PubMed,OVID,EMbase,the Cochrane Library and Chinese Biomedical Database（CBM） for randomized controlled trials on evaluating perioperative β-blockers after noncardiac surgery.The quality of the included studies was evaluated by the method recommended by the Cochrane Collaboration.Meta-analyses was conducted by using the Cochrane Collaboration＇s RevMan software.Results Thirteen RCTs including 11590 patients were included.The combined results of all studies showed cardioprotective effect of β-blockers（OR=0.64,95%CI 0.50 to 0.80,P=0.0001）,with considerable heterogeneity among the studies（I2=57%）.However,grouping the trials on the basis of maximal HR showed that trials where the estimated maximal HR was 100 bpm were associated with cardioprotection（OR=0.37,95%CI 0.26 to 0.52,P0.000 01） whereas trials where the estimated maximal HR was 100 bpm did not demonstrate cardioprotection（OR=1.13,95%CI 0.81 to 1.59,P=0.48） with no heterogeneity（I2=0%）.Conclusion The evidence suggests that effective control of HR is important for achieving cardioprotection and that administration of β-blockers does not reliably decrease HRs in all patients.Judicious use of combination therapy with other drugs may be necessary to achieve effective postoperative control of HR.