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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-T[WMD=1.10,95%CI(0.84,1.36)]和∑ST-T[WMD=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-Td[WMD=9.51,95%CI(4.74,14.27)]、Q-Tcd[WMD=11.82,95%CI(5.55,18.09)]及J-Td[WMD=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。
Objective To evaluate the cardioprotective effect of high thoracic epidural anesthesia (HTEA) on patients with acute coronary syndrome and cardiac insufficiency. Methods The databases of PubMed, EBSCO, Springer, Ovid and CNKI were searched electronically to collect randomized controlled trials and related references of patients undergoing HTEA in patients with acute coronary syndrome or heart failure published between 1990 and 2010. According to the quality evaluation criteria of Cocharane Handbook 5.0.1, the quality evaluation and data extraction were included in the study. The statistical analysis was performed by using RevMan 4.2.10 software. Results A total of 16 self-controlled trials and 12 blank control trials were enrolled. A total of 1 041 patients were enrolled. The results of Meta analysis showed that: ①Effects on cardiac function: HTEA could significantly improve left ventricular ejection fraction [WMD = -10.28,95% CI (-14.14, -6.43)] and cardiac output [WMD = -1.26,95% (WMD = -17.50,95% CI (-1.63, -0.89)], and narrowing the left ventricular end-diastolic diameter [WMD = 5.02,95% CI (3.72,6.32)] and increasing the peak early filling velocity (-29.40, -5.59)], and decreased the maximum filling rate in late diastolic phase (A peak) [WMD = 27.36,95% CI (24.46,30.26)]; ②The effect on myocardial ischemia in patients with cardiac insufficiency: ST-segment depression, T-wave inversion (NST-T) [WMD = 1.45,95% CI (1.12,1.78)] and degree sum (ΣST-T) [WMD = 1.02,95% CI (0.78,1.26)] (WMD = 4.24, 95% CI (0.48, 8.00)], and myocardial ischemia in patients with acute coronary syndrome was significantly reduced Duration of ischemia [WMD = 23.29,95% CI (4.66,42.11)] and the number of episodes of angina [WMD = 3.44,95% CI (0.92,5.97)] decreased NST-T [WMD = 1.10, 95% CI (0.84,1.36)] and ΣST-T [WMD = 1.33,95% CI (1.01,1.65)]; ④The influence on hemodynamics in patients with acute coronary syndrome: resistance (WMD = 8.44, 95% CI (3.81, 13.07)] and decreased systemic resistance [WMD = 2.07,95% CI (0.81, 3.34)] but did not reduce the diastolic blood pressure (WMD = 2.06, 95% CI (-0.52, 4.64)] did not affect coronary perfusion pressure; (5) Effect on QT dispersion: Q-Td was significantly reduced after block [WMD = 9.51,95% CI 4.74, 14.27)], Q-Tcd [WMD = 11.82, 95% CI (5.55, 18.09)] and J-Td [WMD = 9.04, 95% CI (2.30, 15.79)]. Conclusions HTEA can significantly improve left ventricular systolic and diastolic function, slow down heart rate, stabilize hemodynamics, reduce the number and duration of myocardial ischemia in patients with acute coronary syndrome and cardiac insufficiency, and reduce the change of ST segment in ECG and shortening QT dispersion. Due to the quality limitations of the study, the above conclusion still needs more high-quality research to be verified.