吸烟对冠状动脉旁路移植术后近、远期结果影响研究

【作者】 孙海宁；

【导师】 胡盛寿；

【作者基本信息】 北京协和医学院 ， 外科学， 2011， 博士

【摘要】 第一部分：吸烟对冠状动脉旁路移植术后近期结果的影响研究目的：研究吸烟对冠状动脉旁路移植术(Coronary artery bypass grafting, CABG)后近期结果的影响。方法：回顾性分析阜外医院2004年1月至2005～12行冠状动脉旁路移植术2570例患者资料,其中有详细术前吸烟情况记录者共2486例,按照术前吸烟情况分为吸烟组(1457例)和不吸烟组(1029例),其中吸烟组根据术前1个月是否戒烟分为戒烟者(409例)及未戒烟者(1048例),采用Logistic多因素回归分析吸烟及戒烟与住院期间术后早期并发症及死亡率的关系。结果：与不吸烟组患者相比,吸烟组患者接受冠状动脉旁路移植术治疗时年龄较小(P<0.001)；吸烟组患者术后肺部并发症发生率较不吸烟组患者明显增加(3.2%vs1.6%,P=0.010),呼吸机辅助通气时间增加(P=0.016),危险因素矫正分析表明：(1)吸烟组患者发生肺部并发症的风险(relative risk, RR)为不吸烟组患者的1.91倍(95%可信区间confidence interval, CI,1.03-3.56),住院死亡,术后低心输出量综合征,心房颤动,心脏骤停/心室颤动,重症监护病房(Intensive care unit, ICU)停留时间及其他系统并发症等发生率无明显差异。(2)进一步分析表明吸烟组中未戒烟患者发生肺部并发症的风险为不吸烟组患者的2.30倍(95%CI,1.19-4.46);未戒烟患者呼吸机辅助通气时间较不吸烟组增加(P=0.026)；(3)戒烟患者与不吸烟组患者相比住院死亡,术后低心输出量综合征,心房颤动,心脏骤停/心室颤动,重症监护病房停留时间,肺部并发症及其他系统并发症等发生率无明显差异(P>0.05)。结论：吸烟组患者术后肺部并发症明显增加,呼吸机辅助时间延长；术前未戒烟患者术后肺部并发症显著增加,呼吸机辅助时间延长。术前1个月戒烟有助于减少冠状动脉旁路移植术后并发症的发生。第二部分：吸烟对冠状动脉旁路移植术后远期结果影响研究目的：研究吸烟对冠状动脉旁路移植术(CABG)后远期结果的影响。方法：随访阜外医院2004.1-2005.12行冠状动脉旁路移植术的2541例患者,根据患者术前有无吸烟史,分为不吸烟组(1016例)和吸烟组(1441例)；吸烟组患者根据是否戒烟及戒烟时间又进一步分为术前戒烟组(403例),术后戒烟组(496例),持续吸烟组(542例)；其中持续吸烟组又根据每日吸烟量进一步分为<10支/天和≥10支/天两组。终点观察事件包括全因死亡,心因死亡,肿瘤原因死亡,主要心脑血管不良事件(Major adverse cardiac and cerebrovascular events, MACCE)以及心绞痛的发生率,采用单因素及Cox多因素回归分析吸烟状况与不良事件发生率之间的关系。结果：随访时间4.27-6.41年(随访中位时间5.09年),随访率为96.7%,冠状动脉旁路移植术后5年时持续吸烟者比例为22.1%。危险因素调整分析表明：(1)和不吸烟组相比,吸烟组肿瘤原因死亡(RR2.38,95%CI,1.06-5.36),MACCE事件(RR1.26,95%CI,1.01-1.57)及心绞痛(RR1.29,95%CI,1.04-1.59)风险明显升高。(2)与不吸烟组相比,术后持续吸烟患者,全因死亡(RR2.60,95%CI,1.53-4.46),心因死亡(RR2.51,95%CI,1.32-4.78),肿瘤原因死亡(RR5.12,95%CI,2.08-12.59),MACCE事件(RR1.83,95%CI,1.42-2.34)及心绞痛(RR1.69,95%CI,1.33-2.16)发生率风险明显升高；术前戒烟患者及术后戒烟患者死亡风险,MACCE事件发生率及心绞痛发生率与不吸烟组患者相比无统计学差异。(3)进一步分析表明,与不吸烟组相比,<10支/天吸烟者全因死亡(RR2.48,95%CI,1.31-4.69),心因死亡(RR2.41,95%CI,1.12-5.17),肿瘤原因死亡(RR5.06,95%CI,1.87-14.23),MACCE事件(RR1.77,95%CI,1.31-2.39)及心绞痛(RR1.41,95%CI,1.05-1.91)风险升高；≥10支/天吸烟者全因死亡(RR2.76,95%CI,1.43-5.32),心因死亡(RR2.62,95%CI,1.22-5.64)及肿瘤原因死亡(RR4.93,95%CI,1.64-14.85),MACCE事件(RR1.90,95%CI,1.39-2.60)及心绞痛(RR2.07,95%CI1.52-2.84)风险明显升高。(4)与持续吸烟患者≥10支/天相比,<10支/天者虽然心绞痛发生率降低(RR0.68,95%CI,0.47-0.98),但全因死亡风险(RR0.90,95%CI,0.44-1.85),心因死亡(RR0.92,95%CI,0.40-2.10),肿瘤原因死亡(RR1.07,95%CI,0.37-3.10)和MACCE事件发生率(RR0.93,95%CI,0.65-1.33)无明显降低。结论：我国冠状动脉旁路移植术后患者持续吸烟比例仍较高(22.1%),冠状动脉旁路移植术后持续吸烟患者死亡率,主要心脑血管不良事件及心绞痛发生率明显增加,而减少吸烟量并不能明显减少死亡及主要不良心脑血管事件的发生,戒烟将明显减少不良事件的发生。更多还原

【Abstract】 Part one: Effect of Smoking on Early Outcome of Patients Undergoing Coronary Artery Bypass SurgeryObjective:To assess the influence of smoking on early outcome in patients undergoing coronary artery bypass graft surgery (CABG).Methods:We retrospectively analyze2570consecutive patients underwent CABG in Fuwai hospital from January2004to December2005. Of these,1457patients were smokers in which1029patients were current smokers,409were former smokers who stopped smoking more than1month, and1029were nonsmokers. Assess the in-hospital morbidity and mortality of current smokers and former smokers compared with nonsmokers undergoing CABG.Results:Smokers were more likely to be younger (P<0.001), Smokers had higher rates of postoperative pulmonary complications (3.2%vs1.6%, p=0.010) and longer ventilation time was longer (.P=0.016) than nonsmokers. Former smokers had no elevated risks for pulmonary complications or longer ventilation time compared with nonsmokers. The odds ratio (OR) for developing a postoperative pulmonary complication for current smokers vs never smokers was1.91(95%CI,1.03-3.56) after adjustment for age, history of congestive heart failure, history of COPD and so on. And current smokers had longer ventilation time was longer (P=0.026) than nonsmokers Rates of low cardiac output, myocardial infarction, atrial fibrillation, heart arrest/wentricular fibrillation postoperative length of stay in intensive care unit, other postoperative complications, and mortality did not differ between former smokers and nonsmokers.Conclusions:Smoking especially current smoking are associated with significant pulmonary complications and longer ventilation time after CABG, Morbidity and mortality are comparable between former smokers and nonsmokers. Smokers should be encouraged to quit as early as possible, and smoking cessation of1month before CABG was beneficial. Part two: Long-term effects of smoking on patients after coronary artery bypass graft surgery.Objective:The goal of this study was to determine effect of smoking behaviors on long-term outcomes of coronary artery bypass graft surgery (CABG) and effect of different smoking consumption on long-term outcomes of coronary artery bypass graft surgery.Methods:We conduct a survey of2541consecutive patients who underwent CABG in Fuwai hospital, The preoperative and postoperative smoking habits were retrieved, the patients were divided into two groups:never smokers and ever smokers; the ever smokers was further divided into the following groups:persistent smokers who smoked before and after CABG, former smokers who stopped smoking before CABG, quitters who stopped smoking after CABG, and never smokers, the persistent smokers was divided into the following groups:persistent smokers<10cigarettes per day and persistent smokers≥10cigarettes per day, analyzed the morbidity and mortality in univariate and multivariate Cox analysis.Results:The median follow-up was5.09years, the overall response rate was96.7%, in analyses adjusted for baseline characteristics, ever smokers had more elevated relative risk (RR)for tumor related death (RR2.38,95%confidence interval, CI,1.06-5.36), MACCE(RR1.26,95%CI,1.01-1.57) and angina pectoris(RR1.29,95%CI,1.04-1.59) compared with never smokers. The persistent smokers had a greater relative risk of death from all causes (RR2.60,95%CI,1.53-4.46), cardiac death (RR2.51,95%CI,1.32-4.78), tumor related death (RR5.12,95%CI,2.08-12.59), MACCE(RR1.83,95%CI,1.42-2.34) and angina pectoris(RR1.69,95%CI,1.33-2.16) as compared with never smokers. No differences in outcome were found among patients who stopped smoking and never smokers. As compared with never smokers, persistent smokers<10cigarettes per day had a greater relative risk of death from all causes (RR2.48,95%CI,1.31-4.69), cardiac death (RR2.41,95%CI,1.12-5.17), tumor related death (RR5.06,95%CI,1.87-14.23), MACCE (RR1.77,95%CI,1.31-2.39)and angina pectoris(RR1.41,95%CI,1.05-1.91). persistent smokers≥10cigarettes per day had a greater relative risk of death from all causes (RR2.76,95%CI,1.43-5.32), cardiac death (RR2.62,95%CI,1.22-5.64), tumor related death (RR4.93,95%CI,1.64-14.85),MACCE(RR1.90,95%CI,1.39-2.60)and angina pectoris(RR2.07,95%CI,1.52-2.84). Analysis did not reveal significant differences in all causes (RR0.90,95%CI0.44-1.85), cardiac death (RR0.92,95%CI0.40-2.10), tumor related death (RR1.07,95%CI0.37-3.10), and MACCE(RR0.93,95%CI0.65-1.33) but lower incidence of angina pectoris (RR0.68;95%CI:0.47-0.98) between the persistent smokers smoked<10cigarettes per day and those smoked≥10cigarettes per day.Conclusions:Smoking prevalence was still high in patients after CABG in china(22.1%), persistent smoking is associated with higher rates of mortality and morbidity after CABG, smoking cession was associated with reduction of morbidity and mortality. Reduction of smoking daily consumption was not associated with reduction of morbidity and mortality更多还原