上胸段硬膜外阻滞对急性冠脉综合征及心功能不全患者心脏保护作用的系统评价

目的系统评价上胸段硬膜外阻滞（high thoracic epidural anesthesia,HTEA）对急性冠脉综合征、心功能不全患者的心脏保护作用。方法电子检索PubMed、EBSCO、Springer、Ovid、CNKI等数据库,收集发表于1990年至2010年急性冠脉综合征或心功能不全患者行HTEA治疗的随机对照试验及其相关参考文献。按Cocharane Handbook 5.0.1的质量评价标准对纳入研究进行质量评价和资料提取,统计分析采用RevMan 4.2.10软件。结果共纳入16个自身对照试验,12个空白对照试验,共1 041例患者。Meta分析结果显示：①对心功能的影响：HTEA能够显著改善左室射血分数WMD=–10.28,95%CI（–14.14,–6.43）]和心输出量WMD=–1.26,95%CI（–1.63,–0.89）],缩小左室舒张末内径WMD=5.02,95%CI（3.72,6.32）],增加舒张早期最大充盈速度（E峰）WMD=–17.50,95%CI（–29.40,–5.59）],降低舒张晚期最大充盈速度（A峰）WMD=27.36,95%CI（24.46,30.26）];②对心功能不全患者心肌缺血程度的影响：阻滞后ST段压低、T波倒置次数（NST-T）WMD=1.45,95%CI（1.12,1.78）]和程度总和（∑ST-T）WMD=1.02,95%CI（0.78,1.26）]显著减少;③对急性冠脉综合征患者心肌缺血程度的影响：阻滞后能够显著减少急性冠脉综合征患者的心肌缺血WMD=4.24,95%CI（0.48,8.00）]、心肌缺血持续时间WMD=23.29,95%CI（4.66,42.11）]和心绞痛的发作次数WMD=3.44,95%CI（0.92,5.97）],减少NST-TWMD=1.10,95%CI（0.84,1.36）]和∑ST-TWMD=1.33,95%CI（1.01,1.65）]的变化程度;④对急性冠脉综合征患者血流动力学的影响：阻滞后可显著减慢急性冠脉综合征患者的心率WMD=8.44,95%CI（3.81,13.07）],降低体循环阻力WMD=2.07,95%CI（0.81,3.34）],但不降低舒张压WMD=2.06,95%CI（–0.52,4.64）],不影响冠状动脉灌注压;⑤对Q-T离散度的影响：阻滞后能显著降低Q-TdWMD=9.51,95%CI（4.74,14.27）]、Q-TcdWMD=11.82,95%CI（5.55,18.09）]及J-TdWMD=9.04,95%CI（2.30,15.79）]。结论 HTEA能够显著改善急性冠脉综合征及心功能不全患者的左室收缩和舒张功能,减慢心率,稳定血流力学,减少心肌缺血的发生次数和持续时间,减少心电图ST段改变,缩短Q-T离散度。受纳入研究的质量限制,上述结论尚需更多高质量研究加以验证。

Cardiac Protection of High Thoracic Epidural Anesthesia for Patients with Acute Coronary Syndrome or Heart Failure:A Systematic Review

Objective To evaluate the cardiac protection function of high thoracic epidural anesthesia（HTEA） for patients with acute coronary syndrome or heart failure.Methods A literature search was conducted with computer-ized database on PubMed,EBSCO,Springer,Ovid,and CNKI from 1990 to May 2010.Further searches for articles were conducted by checking all references describing cardiac protection studies with HTEA.All included articles were assessed and data were extracted according to the standard of Cochrane review.The homogeneous studies were pooled using Rev-Man 4.2.10 software.Results A total of 28 articles involving 1041 patients were included.The results of meta-analyses showed that,a） cardiac function： HTEA could signi cantly improve ejection fraction of left ventricle（WMD= – 10.28,95%CI – 14.14 to – 6.43） and cardiac output（WMD= – 1.26,95%CI – 1.63 to – 0.89）,contract left ventricular diastolic dimension（WMD= 5.02,95%CI 3.72 to 6.32）,increase E peak（WMD= – 17.50,95%CI – 29.40 to – 5.59） and decrease A peak（WMD= 27.36,95%CI 24.46 to 30.26）;b） ischemic degree for patients with heart failure： the change of NST-T（WMD=1.45,95%CI 1.12 to 1.78） and ∑ST-T（WMD= 1.02,95%CI 0.78 to 1.26） got signi cantly decreased after HTEA;c） ischem-ic degree for patients with acute coronary syndrome： HTEA could obviously lessen the times（WMD= 4.24,95%CI 0.48 to 8.00） and duration（WMD= 23.29,95%CI 4.66 to 42.11） of myocardial ischemia,decrease the times of heart attack（WMD= 3.44,95%CI 0.92 to 5.97）,and decrease the change of NST-T（WMD= 1.10,95%CI 0.84 to 1.36） and ∑ST-T（WMD= 1.33,95%CI 1.01 to 1.65）;d） hemodynamic change for patients with acute coronary syndrome： HTEA could obviously decrease heart beat（WMD= 8.44,95%CI 3.81 to 13.07） and systolic arterial pressure（WMD= 2.07,95%CI 0.81 to 3.34）,but not decrease the diastolic blood pressure（WMD= 2.06,95%CI – 0.52 to 4.64） so as to avoid in uencing the infusion of coro-nary artery;and e） in uence on Q-T interval dispersion： HTEA could signi cantly decrease Q-Td（WMD= 9.51,95%CI 4.74 to 14.27）,Q-Tcd（WMD= 11.82,95%CI 5.55 to 18.09）,and J-Td（WMD= 9.04,95%CI 2.30 to 15.79）.Conclusions High thoracic epidural anesthesia can obviously improve the systolic and diastolic function of left ventricle,decrease the heart beat and stabilize hemodynamic change,lessen the times and duration for myocardial ischemia,reserve the ST segment change,contract Q-T interval dispersion,which has to be further proved with more high quality studies.