远程缺血预处理对心脏术后临床结局的影响—系统评价与meta分析

Effect of remote ischemic preconditioning on clinical outcomes after cardiac surgery:systematic review and meta-analysis

目的评价远程缺血预处理(RIPC)对体外循环心脏术后临床结局的影响。方法检索中国知网(CNKI)、维普、万方、中国生物医学文献数据库(CBM)、Pubmed、EMBASE、Cochrane对照试验中心注册库(CENTRAL)数据库,检索时间为建库至2020年3月2日,采用主题词+自由词的方法,搜集关于RIPC应用于心脏手术的随机对照试验。共纳入随机对照试验23项,患者5045例,按照缺血预处理方式分为RIPC组(2524例)和对照组(2521例)。实验组采用麻醉诱导后远程缺血预处理,上、下肢均可;对照组采用相同部位假缺血处理,比较两组指标差异。主要结局指标为术后不良事件发生率、病死率和肌钙蛋白I值,次要结局指标为重症监护病房住院时间、机械通气时间、住院总时间。二分类结局变量采用相对危险度(RR)及95%可信区间(95%CI)表示,连续性数值变量采用均数差(MD)或标准化均数差(SMD)的95%CI表示。因文献术后72 h肌钙蛋白I曲线下面积的研究间存在不可接受的异质性,放弃meta分析,仅作定性分析。结果两组围手术期不良事件发生率比较,包括急性心肌梗死(RR=0.92,95%CI:0.79~1.07,P=0.27)、急性肾损伤(AKI)(RR=1.01,95%CI:0.90~1.14,P=0.83)、术后新发房颤(RR=0.98,95%CI:0.83~1.15,P=0.77)、卒中(RR=0.96,95%CI:0.61~1.50,P=0.84)及病死率(RR=1.27,95%CI:0.84~1.91,P=0.26),差异均无统计学意义(P>0.05)。结论未发现RIPC改善体外循环心脏术后临床结局证据,其心肌保护作用有待进一步证实。

Objective To access the benefits and harms of remote ischemic preconditioning(RIPC)in patients undergoing cardiac surgery with cardiopulmonary bypass.Methods An electronic and manual search of literature published before Mar 2020 was conducted using Pubmed,EMBASE,Cochrane Library for randomized controlled trials(RCTs),CNKI,CBM,WanFang and VIP.23 studies involving in 5025 participants were included.Patients were randomly assigned to either remote ischemic preconditioning group(n=2524)or control group(n=2521).Remote ischemic preconditioning consisted of 3-4 cycles of lower limbs or upper limbs ischemia and reperfusion with an automated cuff inflator.Clinical data and the levels of injury biomarkers were collected.The main outcomes were the incidence of adverse events,mortality in the hospital,and the post-operative troponin concentration.The effective values of dichotomous variables or continuous variables were estimated by Relative risk(RR)or by mean differences(MD),standardized mean differences(SMD)with 95%confidence intervals(CI)respectively.Results In general risk of bias varied from low to moderate risk of bias across included studies,and insufficient detail was provided to inform judgement in several cases.There were no significant differences between the two groups with regard to all-cause mortality in hospital(RR=1.27,95%CI:0.84-1.91,P=0.26),no-fatal myocardial infarction(RR=0.92,95%CI:0.79-1.07,P=0.27),new stroke(RR=0.96,95%CI:0.61-1.50,P=0.84),new atrial fibrillation(RR=0.98,95%CI:0.83-1.15,P=0.77)and acute renal failure(RR=1.01,95%CI:0.90-1.14,P=0.83).Conclusion There is no evidence that RIPC has a treatment effect on clinical outcomes(measured as all-cause mortality in hospital,no-fatal myocardial infarction,new stroke,new atrial fibrillation,and acute renal failure).More research should be designed to confirm the effect of RIPC on myocardial protection with cardiopulmonary bypass.