性别因素和处理策略对远隔缺血预处理减轻心脏手术患者心肌损伤的影响：meta分析

Effect of gender and treatment strategy on remote ischemic preconditioning-induced reduction of myocardial damage in patients undergoing cardiac surgery： a meta analysis

目的采用meta分析评价性别因素和处理策略对远隔缺血预处理减轻心脏手术患者心肌损伤的影响。方法以相应关键词系统检索PubMed、EMbase、Cochrane Library数据库（检索时间限定为1990年2月至2012年2月）纳入以英文公开发表有关远隔缺血预处理在成年患者心脏手术中产生心肌保护作用的随机对照试验（RCT）。分析术后心肌损伤标志物水平，计算标准化均差（SMD）。采用发表偏倚和敏感性分析判断结果的可信度。采用Stata12．0软件进行meta分析。结果纳入13篇RCT，共985例患者。与对照组比较，远隔缺血预处理明显降低患者术后血清心肌损伤标志物水平（SMD=-0．539；95％CI：-0．926～-0．152；P〈0．05），具有明显异质性（I^2=88．7％；P〈0．01）。此结果不存在明显的发表偏倚（P=0．083，Begg检验；P=0．077，Egger检验），且敏感性分析显示每个独立的研究对总效应尺度的幅度和方向无明显影响（P〉0．05），结果可信度较高。meta分析结果显示男性（％，回归系数=0．02；95％CI：-0．002～0．042；P〈0．1；校正R^2=19．61％）和总缺血时间（min，回归系数=-0．08；95％CI：-0．154～0．002；P〈0．1；校正R^2=19．47％）是影响远隔缺血预处理减轻心脏手术患者心肌损伤的因素。结论性别因素可影响远隔缺血预处理减轻患者心脏手术后心肌损伤的效果，减轻女性患者心肌损伤的效果优于男性，适当增加单次缺血时间或总次数可获得更佳的效果。

Objective To evaluate the effect of gender and treatment strategy on remote ischemic precon- ditioning （RIPC）-induced reduction of myocardial damage in patients undergoing cardiac surgery. Methods We systematically searched the literature in PubMed, EMBase, and C0chrane Library （from Feb 1990 to Feb 2012） using the related keywords. Randomized control trials （RCTs） published in English with report on postoperative bi- omarkers of myocardial damage concerning RIPC-induced myocardial protection in adult patients undergoing cardiac surgery were included. Standardized mean difference （SMD） was calculated. Publication bias and sensitivity anal- ysis were used to evaluate the reliability of overall enzymatic estimate. Meta-regression analysis was performed to explore the potential sources of significant heterogeneity among results of studies. Data were analyzed using Stata 12.0.Results Thirteen RCTs involving 985 patients were included in our study. Compared with controls, RIPC significantly reduced postoperative serum levels of biomarkers of myocardial damage with significant heterogeneity （SMD= -0.539; 95%CI： -0.926to -0.152; P〈0.05; 12=88.7%, P〈0.01）. No evidence of obvious publication bias was observed （ P = 0.083, Begg＇ s test; P = 0.077, Egger＇ s test）. Sensitivity analysis showed that each individual study produced no effect on the direction and magnitude of the overall effect size （ P 〈 0.05）. Meta-regression analysis revealed that male （ % ） （ coefficient = 0.02 ; 95 % CI ： - 0. 002-0. 042 ; P = 0.070 ; ad- justed R2 = 19.61%） and total isehemic time （rain） （coefficient = -0.08; 95% CI： -0.154-0.002; P = 0. 055 ; adjusted R2 = 19.47 % ） were the two major influential factors. Conclusion Gender affects R/PC-induced reduction of myocardial damage after cardiac surgery in patients, RIPC-induced reduction of myocardial damage in female patients is superior to that in male patients and a better efficacy can be achieved by prolonging the single ischemic time or by increasing the ischemic cycles.