40~49岁未行术前CAG的开胸心脏手术患者冠状动脉事件发生率及其相关因素

The incidence and related factors of coronary events among 40-49 years old patients undergoing cardiac thoracotomy without preoperative CAG

目的了解40~49岁未行术前冠状动脉造影(CAG)的开胸心脏手术患者远期冠状动脉事件的发生率及其相关因素。方法本研究为回顾性研究。入选2009年12月至2017年5月在南京鼓楼医院心胸外科因瓣膜病、先天性心脏病、大血管疾病及其他非冠心病行开胸心脏手术、年龄介于40~49岁的患者。据临床症状怀疑为冠心病或冠状动脉CT血管成像提示冠状动脉钙化者,术前予以CAG检查,其余患者术前均未接受CAG检查。术后对未接受CAG检查的患者进行电话随访。主要终点事件包括冠状动脉相关性死亡及接受冠状动脉旁路移植术(CABG)或经皮冠状动脉介入治疗(PCI);次要终点事件包括新发心绞痛、临床诊断冠心病;其他终点事件有心原性死亡及全因死亡。冠状动脉事件包括主要和次要终点事件。根据术后随访是否出现冠状动脉事件将未接受CAG检查的患者分为冠状动脉事件阳性组和冠状动脉事件阴性组。记录未接受CAG检查患者的远期终点事件发生情况,并对比冠状动脉事件阳性组和冠状动脉事件阴性组患者临床资料的差异。结果共入选952例患者,年龄(45.2±2.7)岁,男性406例(42.65%)。73例患者术前行CAG检查,其中9例(12.32%)为CAG阳性,这部分患者同期行CABG。879例术前未行CAG的患者中,围手术期(住院期间及出院30 d内)死亡18例(2.05%),随访(61.6±25.8)个月,失访28例(3.25%)。术后远期随访中,均未出现冠状动脉相关性死亡及接受PCI或CABG治疗等主要终点事件;4.41%(38/861)的患者发生次要终点事件,均表现为术后偶发的非典型心绞痛。远期冠状动脉事件发生率、全因死亡率及心原性死亡率分别为4.41%(38/861)、1.16%(10/861)、0.46%(4/861)。冠状动脉事件阳性组患者合并高血压的比例高于冠状动脉事件阴性组[34.21%(13/38)比20.89%(164/785),P=0.045]。结论在我国40~49岁行开胸手术的非冠心病患者术前不常规行CAG检查是可行的,但需谨慎对待合并高血压等冠心病危险因素者。

Objective To investigate the long-term incidence of coronary events and related factors in patients undergoing cardiac thoracotomy without preoperative coronary angiography(CAG).Methods This was a retrospective study.The clinical data of patients,aged between 40 and 49 years old,who underwent cardiothoracic surgery,including heart valve surgery,congenital heart disease surgery,cardio great vessels surgery and other non-coronary artery disease(CAD)surgery,in Nanjing Drum Tower Hospital from December 2009 to May 2017,were enrolled.Patients with suspected CAD,or patients with coronary CTA defined calcified coronary arteries received CAG examination prior operation,and the rest patients did not receive routine CAG examinations.The patients who did not receive routine CAG examinations were followed up by telephone.The primary endpoints include death related to coronary arteries,coronary artery bypass graft(CABG)or percutaneous coronary intervention(PCI).The secondary endpoints include the new onset angina,clinically diagnosed CAD or receiving the first and second prevention for CAD.The other outcome events included cardiac death and all-cause mortality.The primary and secondary endpoints were all regarded as coronary events.The patients without preoperative CAG were divided into two groups:the positive group and the negative group,according to the incidence of coronary events during follow-up.Clinical data were compared between the two groups.Results A total of 952 patients were included.The age was(45.2±2.7)years old,406(42.65%)patients were male.Preoperative CAG was performed in 73 patients,among whom 9(12.32%)patients underwent simultaneous CABG.Among the 879 cases who did not undergo coronary angiography before the operation,18(2.05%)died during perioperative period(hospitalization and within 30 days after discharge).The patients were followed up for(61.6±25.8)months,and 28(3.25%)patients were lost to follow up.During long-term follow up,there were no fatal cases due to severe coronary events and no cases of CABG or PCI.Only 4.41%(38/861)patients had the secondary endpoints,namely the occasional onset of atypical angina.The incidence rate of the long-term coronary events,all-cause mortality and cardiac death were 4.41%(38/861),1.16%(10/861),0.46%(4/861)during long-term follow-up.The prevalence of hypertension was significantly higher in positive group than negative group(34.21%(13/38)vs.20.89%(164/785),P=0.045).Conclusions It is feasible not to perform preoperative CAG examination for non-CAD patients aged 40-49 years who will undergo cardiac thoracotomy.However,we need to be aware the risk of coronary events in the patients complicating with risk factors of CAD,such as hypertension.