既往 NSTEMI 与非心脏手术后重大心脑血管不良事件的发生时间。

IF 15.7 1区 医学 Q1 SURGERY JAMA surgery Pub Date : 2024-10-30 DOI:10.1001/jamasurg.2024.4683
Laurent G Glance, Karen E Joynt Maddox, Sabu Thomas, Mark J Sorbero, Lee A Fleisher, Stewart J Lustik, Heather L Lander, Jingjing Shang, Patricia W Stone, Michael P Eaton, Marjorie S Gloff, Andrew W Dick
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The odds of postoperative MACCE leveled off after 30 days in patients who had undergone any coronary revascularization procedure (and after 90 days in patients with drug-eluting stents) and then increased after 180 days (any revascularization at 181-365 days: aOR, 1.46; 95% CI, 1.25-1.71; P < .001; patients with drug-eluting stents at 181-365 days: aOR, 1.73; 95% CI, 1.42-2.12; P < .001). The odds of MACCE did not level off for patients who did not have revascularization. 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引用次数: 0

摘要

重要性:在最近发生急性心肌梗死后推迟择期非心脏手术与更好的预后有关,但美国心脏协会目前的建议是基于20多年前的数据:目的:研究非 ST 段抬高型心肌梗死(NSTEMI)发生后的时间与术后主要不良心脑血管事件(MACCE)风险之间的关系:这项横断面研究检查了 2015 年至 2020 年期间 67 岁或以上接受过非心脏大手术患者的医疗保险报销数据。数据分析时间为 2023 年 9 月 21 日至 2024 年 2 月 1 日。暴露:既往 NSTEMI 与手术之间的时间间隔:MACCE(30 天死亡率、院内心肌梗死、心力衰竭或中风)和全因 30 天死亡率。采用多变量逻辑回归估计结果与既往NSTEMI发生时间之间的关系:样本包括 5 227 473 例手术。平均(标清)年龄为 75.7(6.6)岁;女性 2 981 239 人(57.0%),男性 2 246 234 人(43%)。42 278 名患者(0.81%)曾患过 NSTEMI。与既往未患 NSTEMI 的患者相比,在择期手术后 30 天内患 NSTEMI 的患者无论是否接受过冠状动脉血运重建,发生 MACCE 的几率都更高(调整后的几率比 [aOR],2.15;95% CI,1.09-4.23;P = .03)(aOR,2.04;95% CI,1.31-3.16;P = .001)。接受过任何冠状动脉血运重建手术的患者术后发生 MACCE 的几率在 30 天后趋于平稳(使用药物洗脱支架的患者在 90 天后趋于平稳),在 180 天后有所上升(181-365 天接受过任何血运重建手术:aOR,1.46;95% CI,1.25-1.71;P 结论及意义:本研究发现,在接受非心脏手术并进行血管重建的老年患者中,术后 MACCE 和死亡率的几率在 30 到 90 天之间趋于平稳,然后在 180 天后上升。而未接受血管重建手术的患者的几率并没有趋于平稳。对于接受过血管重建手术的患者来说,将择期非心脏手术推迟到 NSTEMI 后 90 天到 180 天之间可能是合理的。
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Time Since Prior NSTEMI and Major Adverse Cardiovascular and Cerebrovascular Events After Noncardiac Surgery.

Importance: Delaying elective noncardiac surgery after a recent acute myocardial infarction is associated with better outcomes, but current American Heart Association recommendations are based on data that are more than 20 years old.

Objective: To examine the association between the time since a non-ST-segment elevation myocardial infarction (NSTEMI) and the risk of postoperative major adverse cardiovascular and cerebrovascular events (MACCE).

Design, setting, and participants: This cross-sectional study examined Medicare claims data between 2015 and 2020 for patients 67 years or older who had major noncardiac surgery. Data were analyzed from September 21, 2023, to February 1, 2024.

Exposure: Time elapsed between a prior NSTEMI and surgery.

Main outcomes and measures: MACCE (30-day mortality, in-hospital myocardial infarction, heart failure, or stroke) and all-cause 30-day mortality. Multivariable logistic regression was used to estimate the association between outcomes and time since a prior NSTEMI.

Results: The sample included 5 227 473 surgeries. The mean (SD) age was 75.7 (6.6) years; 2 981 239 (57.0%) were female, and 2 246 234 (43%) were male. There were 42 278 patients (0.81%) with a previous NSTEMI. Compared with patients without a prior NSTEMI, patients with an NSTEMI within 30 days of elective surgery had higher odds of MACCE, regardless of whether they had undergone coronary revascularization (adjusted odds ratio [aOR], 2.15; 95% CI, 1.09-4.23; P = .03) or not (aOR, 2.04; 95% CI, 1.31-3.16; P = .001). The odds of postoperative MACCE leveled off after 30 days in patients who had undergone any coronary revascularization procedure (and after 90 days in patients with drug-eluting stents) and then increased after 180 days (any revascularization at 181-365 days: aOR, 1.46; 95% CI, 1.25-1.71; P < .001; patients with drug-eluting stents at 181-365 days: aOR, 1.73; 95% CI, 1.42-2.12; P < .001). The odds of MACCE did not level off for patients who did not have revascularization. Findings for all-cause 30-day mortality were similar to those for MACCE, except that the odds of mortality in patients with previous NSTEMI who had revascularization leveled off after 60 days in elective surgeries and 90 days for nonelective surgeries (elective 30-day: aOR, 2.88; 95% CI, 1.30-6.36; P = .009; elective 61- to 90-day: aOR, 1.03; 95% CI, 0.57-1.86; P = .92; nonelective 30-day: aOR, 1.91; 95% CI, 1.52-2.40; P < .001; nonelective 91- to 120-day: aOR, 1.00; 95% CI, 0.73-1.37; P = .99).

Conclusions and relevance: This study found that among older patients undergoing noncardiac surgery who had revascularization, the odds of postoperative MACCE and mortality leveled off between 30 and 90 days and then increased after 180 days. The odds did not level off for patients who did not have revascularization. Delaying elective noncardiac surgery to occur between 90 and 180 days after an NSTEMI may be reasonable for patients who have had revascularization.

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来源期刊
JAMA surgery
JAMA surgery SURGERY-
CiteScore
20.80
自引率
3.60%
发文量
400
期刊介绍: JAMA Surgery, an international peer-reviewed journal established in 1920, is the official publication of the Association of VA Surgeons, the Pacific Coast Surgical Association, and the Surgical Outcomes Club.It is a proud member of the JAMA Network, a consortium of peer-reviewed general medical and specialty publications.
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