围术期艾司洛尔的安全性：随机对照试验的系统回顾与荟萃分析

背景尽管发现β受体阻滞剂能够减少围术期心肌梗死（myocardial infarction，MI）的发生，但是β受体阻滞剂导致的低血压与术后卒中和死亡相关。本系统回顾中我们评估了特异性β1-肾上腺素受体拮抗剂艾司洛尔在非心脏手术中的安全性和有效性，通过对术后低血压和心动过缓发生率的分析评估安全性，通过对心肌缺血发生率的分析评估有效性。方法我们在电子数据库中检索在非心脏手术围术期使用艾司洛尔的随机安慰剂对照试验。提取设计、人口统计学、血流动力学变化（有计划的或无计划的）、心肌缺血以及心肌梗死的数据，通过荟萃回归评估其异质性来源。结果我们的研究汇集了研究特点完全匹配的67个试验。研究质量受限于小样本并缺乏分配隐匿性的详细说明。总之，分析证明了无计划低血压的发生率增加[OR2．13；95％可信区间（confidenceinterval，CI），1．48-3．04]，并且与剂量相关（R^2=0．408）。未证实心动过缓的发生率有明显增加（OR1．18；95％CI，0．69-2．02）。剂量滴定表现为对动脉血压和心率均有影响。与安慰剂相比，在7项评估研究中艾司洛尔减少了心肌缺血的发生（OR＆17；95％CI，0.02-0．45）。我们没有评估艾司洛尔对心肌梗死和卒中的发生率的影响，因为在检索研究中这些事件极少发生。结论这篇回顾研究表明艾司洛尔能够安全有效地滴定血流动力学至设定的终点。我们还需要对高危患者的安全性数据进行研究，以建立围术期艾司洛尔的安全性和有效性模型。

BACKGROUND： Although β blockers have been found to decrease perioperative myocardial infarction （M1）, β-blocker-mediated hypotension is associated with postoperative stroke and mortality. In this systematic review we assessed the safety and efficacy of the β1-specific, adrenergic receptor antagonist esmolol in noncardiac surgery. Safety was assessed by analyzing the incidence of postoperative hypotension and bradycardia, and efficacy was assessed by analyzing the incidence of myocardial ischemia. METHODS： We searched electronic databases for randomized placebo-controlled trials of the perioperative use of esmolol in noncardiac surgery. We abstracted data on design, demographics, hemodynamic changes （planned or unplanned）, myocardial ischemia, and MI. Heterogeneity was assessed via meta-regression. RESULTS： Our search identified 67 trials, which were well matched for study characteristics. The quality of the studies was limited by small sample size and poorly defined allocation concealment. Overall, the analysis demonstrates an increased incidence of unplanned hypotension （OR 2.13;95 % confidence interval [ CI ], 1.48 to 3.04）, which was found to be dose related （R2 = 0. 408）. An increased incidence of significant bradycardia was not demonstrated （OR 1.18; 95% CI, 0. 69 to 2.02）. Dose titration was shown to influence both the change in arterial blood pressure and heart rate. In comparison with placebo, esmolol decreased the frequency of myocardial ischemia in the 7 evaluating studies （OR 0. 17; 95% CI, 0. 02 to 0.45 ）. We did not assess the effects of esmolol on the incidence of MI or stroke because the incidence of these events was too infrequent in the retrieved studies. CONCLUSIONS： This review suggests that titration of esmolol to a hemodynamic end point can be safe and effective. Safety data from studies in higher-risk patients are needed to establish a perioperative safety and efficacy profile of esmolol.