非体外循环冠状动脉旁路移植术术前空腹血糖与住院期间不良事件的关系
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摘要
目的:通过回顾性分析我院接受非体外循环冠状动脉旁路移植术(OPCAB)的急性冠状动脉综合征(ALS)患者,在术前FBG控制情况与住院期间复合不良事件的关系,探讨糖尿病患者术前FBG的合理控制范围,为OPCAB术前血糖干预目标提供依据。方法:选取2013年6月1日至2015年7月19日,于首都医科大学附属北京安贞医院心外科接受首次OPCAB术的ACS患者1 039例。收集患者人口统计学资料、临床病史、用药史、入院FBG及住院期间不良事件等资料。将患者按照有无糖尿病史分为两组,糖尿病组按入院FBG控制情况分为四个亚组,非糖尿病组按入院FBG四分位间距分为四个亚组,各亚组间比较住院期间复合不良事件、急性肾损害及主要不良心脑血管事件等发生率。结果:与非糖尿病组相比,糖尿病组(DM)的复合不良事件发生率更高(22.9%vs. 16.9%,P<0.05);其中急性肾损害发生率更高(18.5%vs. 11.3%,P<0.05);而主要不良心脑血管事件发生率较低(1.9%vs. 3.0%),但差异无统计学意义。再分别对DM组和NDM组的入院FBG分亚组比较,发现两组入院基线FBG过低或者过高均与较高复合不良事件发生率有关。当DM组控制在6.0～6.9 mmol/L时,住院期间发生复合不良事件的发生率最低(P>0.05)。结论:对首次接受OPCAB的ALS患者,术前FBG影响住院期间复合不良事件。较低或者过高的基线FBG均与住院期间复合不良事件发生率有关。合理地控制患者术前FBG能降低住院期间复合不良事件的发生。
Objective: The relationship between preoperative FBG control and compound adverse events in patients with acute coronary syndrome(ACS) undergoing off-pump coronary artery bypass grafting(OPCAB) in our hospital was analyzed retrospectively. To explore the reasonable control range of FBG in patients with diabetes mellitus before operation, and to provide basis for intervention goal of OPCAB preoperative blood glucose. Methods: From June 1, 2013 to July 19, 2015,choose 1039 patients with ACS underwent the first OPCAB at Beijing Anzhen Hospital. The data of demographics, clinical history, medication, fasting blood glucose and adverse events during hospitalization were collected. The patients were divided into two groups according to the history of diabetes mellitus. The diabetic group was divided into four subgroups according to the level of FBG control in admission, and the non-diabetic group was divided into four subgroups according to the interquartile range of fasting blood glucose in admission. The incidence of compound adverse events, acute renal injury and major adverse cardiovascular events were compared among subgroups. Results: Compared with non-diabetic group, the incidence of compound adverse events in diabetic group was higher(22. 9% vs. 16. 9%, P<0. 05), and the incidence of acute renal injury was higher(18. 5% vs. 11. 3,P<0. 05), while the incidence of major adverse cardiovascular and cerebrovascular events was lower(1. 9% vs. 3. 0%) than that of non diabetic group(P<0. 05), but the difference was not statistically significant. Compared with the subgroup of FBG in DM group and NDM group, it was found that too low or too high baseline FBG in both groups was related to the high compound adverse events. When FBG was controlled between 6.0-6.9 mmol/L in DM group, the incidence of compound adverse events during hospitalization was the lowest(P>0.05).Conslusions:In patients with ACS undergoing OPCAB for the first time, preoperative FBG affected compound adverse events during hospitalization. Lower or higher baseline FBG was associated with the incidence of compound adverse events during hospitalization. Reasonable control of preoperative FBG can reduce the incidence of compound adverse events during hospitalization.
Objective: The relationship between preoperative FBG control and compound adverse events in patients with acute coronary syndrome(ACS) undergoing off-pump coronary artery bypass grafting(OPCAB) in our hospital was analyzed retrospectively. To explore the reasonable control range of FBG in patients with diabetes mellitus before operation, and to provide basis for intervention goal of OPCAB preoperative blood glucose. Methods: From June 1, 2013 to July 19, 2015,choose 1039 patients with ACS underwent the first OPCAB at Beijing Anzhen Hospital. The data of demographics, clinical history, medication, fasting blood glucose and adverse events during hospitalization were collected. The patients were divided into two groups according to the history of diabetes mellitus. The diabetic group was divided into four subgroups according to the level of FBG control in admission, and the non-diabetic group was divided into four subgroups according to the interquartile range of fasting blood glucose in admission. The incidence of compound adverse events, acute renal injury and major adverse cardiovascular events were compared among subgroups. Results: Compared with non-diabetic group, the incidence of compound adverse events in diabetic group was higher(22. 9% vs. 16. 9%, P<0. 05), and the incidence of acute renal injury was higher(18. 5% vs. 11. 3,P<0. 05), while the incidence of major adverse cardiovascular and cerebrovascular events was lower(1. 9% vs. 3. 0%) than that of non diabetic group(P<0. 05), but the difference was not statistically significant. Compared with the subgroup of FBG in DM group and NDM group, it was found that too low or too high baseline FBG in both groups was related to the high compound adverse events. When FBG was controlled between 6.0-6.9 mmol/L in DM group, the incidence of compound adverse events during hospitalization was the lowest(P>0.05).Conslusions:In patients with ACS undergoing OPCAB for the first time, preoperative FBG affected compound adverse events during hospitalization. Lower or higher baseline FBG was associated with the incidence of compound adverse events during hospitalization. Reasonable control of preoperative FBG can reduce the incidence of compound adverse events during hospitalization.
引文
[1] Furnary A, Gao G, Grunkemeier G, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg, 2003,125:1007-1021.
[2] 杨秀秀, 苏工. 2型糖尿病患者血糖变异性与冠状动脉病变程度之间的关系. 心肺血管病杂志, 2017,36(6):440-443.
[3] Estrada C, Young J, Nifong L, et al. Outcomes and perioperative hyperglycemia in patients with or without diabetes mellitus undergoing coronary artery bypass grafting. Ann Thorac Surg, 2003,75:1392-1399.
[4] Duncan A. Hyperglycemia and perioperative glucose management. Curr Pharm Des, 2012,18:6195-6203.
[5] Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J,2014,35:2541-2619.
[6] Farmer J. Strategies for multivessel revascularization in patients with diabetes: the FREEDOM trial. Curr Atheroscler Rep, 2014,16:426.
[7] Lattouf O, Thourani V, Kilgo P, et al. Influence of on-pump versus off-pump techniques and completeness of revascularization on long-term survival after coronary artery bypass. Ann Thorac Surg, 2008,86:797-805.
[8] Dungan K, Braithwaite S, Preiser J. Stress hyperglycaemia. Lancet. 2009,373:1798-1807.
[9] Renner A, Zittermann A, Aboud A, et al. Coronary revascularization in diabetic patients: off-pump versus on-pump surgery. Ann Thorac Surg,2013,96:528-534.
[10] Cavallaro P, Itagaki S, Seigerman M, et al. Operative mortality and stroke after on-pump vs off-pump surgery in high-risk patients: an analysis of 83,914 coronary bypass operations. Eur J Cardiothorac Surg,2014,45:159-164.
[11] Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. DC, 2010,33:1783-1788.
[12] Imran S, Ransom T, Buth K, et al. Impact of admission serum glucose level on in-hospital outcomes following coronary artery bypass grafting surgery. Can J Cardiol,2010,26:151-154.
[13] 张国英,邓微,李晓玉. 糖尿病患者围手术期血糖控制标准的探讨,中华全科医师杂志,2003,2:101-103.
[14] Whitcomb B, Pradhan E, Pittas A, et al. Impact of admission hyperglycemia on hospital mortality in various intensive care unit populations. Crit Care Med,2005,33:2772-2777..
[15] Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clinic Proceedings,2003,12:1471-1478.
[16] Guvener M, Pasaoglu I, Demircin M, et al. Perioperative hyperglycemia is a strong correlate of postoperative infection in type II diabetic patients after coronary artery bypass grafting. Endocr J, 2002,49:531-537.
[17] Van den Berghe G, Wilmer A, Milants I, et al. Intensive insulin therapy in mixed medical/surgical intensive care units:Benefit versus harm. Diabetes, 2006,55:3151-3159.
[18] Zindrou D, Taylor K, Bagger J. Admission plasma glucose: an independent risk factor in nondiabetic women after coronary artery bypass grafting. Diabetes Care, 2001,24:1634-1639.
[19] Ling Y, Li X, Gao X. Intensive versus conventional glucose control in critically ill patients: a meta-analysis of randomized controlled trials. Eur J Intern Med, 2012,23:564-574.
[20] Brunkhorst F, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med, 2008,358:125-139.
[21] Finfer S, Chittock D, Su S, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med, 2009,360:1283-1297.
[22] Moghissi ES, Korytkowski MT, DiNardo M, et al. American association of clinical endocrinologists and American diabetes association consensus statement on inpatient glycemic control. DC, 2009, 6:1119-1131.
[2] 杨秀秀, 苏工. 2型糖尿病患者血糖变异性与冠状动脉病变程度之间的关系. 心肺血管病杂志, 2017,36(6):440-443.
[3] Estrada C, Young J, Nifong L, et al. Outcomes and perioperative hyperglycemia in patients with or without diabetes mellitus undergoing coronary artery bypass grafting. Ann Thorac Surg, 2003,75:1392-1399.
[4] Duncan A. Hyperglycemia and perioperative glucose management. Curr Pharm Des, 2012,18:6195-6203.
[5] Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J,2014,35:2541-2619.
[6] Farmer J. Strategies for multivessel revascularization in patients with diabetes: the FREEDOM trial. Curr Atheroscler Rep, 2014,16:426.
[7] Lattouf O, Thourani V, Kilgo P, et al. Influence of on-pump versus off-pump techniques and completeness of revascularization on long-term survival after coronary artery bypass. Ann Thorac Surg, 2008,86:797-805.
[8] Dungan K, Braithwaite S, Preiser J. Stress hyperglycaemia. Lancet. 2009,373:1798-1807.
[9] Renner A, Zittermann A, Aboud A, et al. Coronary revascularization in diabetic patients: off-pump versus on-pump surgery. Ann Thorac Surg,2013,96:528-534.
[10] Cavallaro P, Itagaki S, Seigerman M, et al. Operative mortality and stroke after on-pump vs off-pump surgery in high-risk patients: an analysis of 83,914 coronary bypass operations. Eur J Cardiothorac Surg,2014,45:159-164.
[11] Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. DC, 2010,33:1783-1788.
[12] Imran S, Ransom T, Buth K, et al. Impact of admission serum glucose level on in-hospital outcomes following coronary artery bypass grafting surgery. Can J Cardiol,2010,26:151-154.
[13] 张国英,邓微,李晓玉. 糖尿病患者围手术期血糖控制标准的探讨,中华全科医师杂志,2003,2:101-103.
[14] Whitcomb B, Pradhan E, Pittas A, et al. Impact of admission hyperglycemia on hospital mortality in various intensive care unit populations. Crit Care Med,2005,33:2772-2777..
[15] Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clinic Proceedings,2003,12:1471-1478.
[16] Guvener M, Pasaoglu I, Demircin M, et al. Perioperative hyperglycemia is a strong correlate of postoperative infection in type II diabetic patients after coronary artery bypass grafting. Endocr J, 2002,49:531-537.
[17] Van den Berghe G, Wilmer A, Milants I, et al. Intensive insulin therapy in mixed medical/surgical intensive care units:Benefit versus harm. Diabetes, 2006,55:3151-3159.
[18] Zindrou D, Taylor K, Bagger J. Admission plasma glucose: an independent risk factor in nondiabetic women after coronary artery bypass grafting. Diabetes Care, 2001,24:1634-1639.
[19] Ling Y, Li X, Gao X. Intensive versus conventional glucose control in critically ill patients: a meta-analysis of randomized controlled trials. Eur J Intern Med, 2012,23:564-574.
[20] Brunkhorst F, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med, 2008,358:125-139.
[21] Finfer S, Chittock D, Su S, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med, 2009,360:1283-1297.
[22] Moghissi ES, Korytkowski MT, DiNardo M, et al. American association of clinical endocrinologists and American diabetes association consensus statement on inpatient glycemic control. DC, 2009, 6:1119-1131.