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ARCH INTERN MED:输血增心梗患者死亡风险

2013-01-04 ARCH INTERN MED CMT 李妍 编译

    对于心肌梗死患者,输血能否带来获益尚存争议。一项美国和丹麦联合研究显示,与不输血或严格的输血策略相比,输血及宽松的输血策略与全因死亡率增加相关。因此,不推荐对心肌梗死患者采取常规输血或宽松的输血策略。论文12 月24日在线发表于《内科学文献》(Arch Intern Med)杂志。   研究者检索MEDLINE、EMBASE、CINAHL等数据库

输血增心梗患者死亡风险
 

  对于心肌梗死患者,输血能否带来获益尚存争议。一项美国和丹麦联合研究显示,与不输血或严格的输血策略相比,输血及宽松的输血策略与全因死亡率增加相关。因此,不推荐对心肌梗死患者采取常规输血或宽松的输血策略。论文12 月24日在线发表于《内科学文献》(Arch Intern Med)杂志。

  研究者检索MEDLINE、EMBASE、CINAHL等数据库,选取1966年1月1日至2012年3月31日间比较输血和不输血以及采取宽松或严格输血策略的10项研究(203665例患者)进行分析。结果为,心肌梗死时,与不输血者相比,接受输血者全因死亡率升高[18.2%对10.2%,风险比(RR)为2.91,P<0.001],加权绝对风险增加12%,NNH(需要治疗多少例就会出现1例差结局)为8。多变量荟萃回归分析显示,输血与死亡率增加相关,且该结果与基线血红蛋白水平、最低血红蛋白水平和住院期间血红蛋白水平变化无关。此外,输血还与再发心肌梗死风险较高相关(RR为2.04,P=0.03)。

  ■ 同期述评

  输血能“杀死”患者?

  美国新泽西医科和牙科大学 贾森(Garson)和加拿大渥太华医院研究中心 海博特(Hebert)

  输血比贫血更能增加心肌梗死患者死亡率?本次发表于《内科学文献》的文章这样告诉我们。但我们并不这样认为。

  对于多数临床医生而言,输血是挽救致命的复杂性贫血的重要手段。与本研究选取的研究角度相比,像“对于多数患者而言,安全的输血指征(血红蛋白水平)是什么?”或“哪些急性心肌梗死患者发生贫血风险更高?”等问题显然更贴近临床实践。

  本研究纳入10项试验进行荟萃分析,其中仅1项为小样本随机对照试验,其余均为观察性研究。在分析中,研究者遗漏了重要临床信息,例如并未充分考虑输血前的血红蛋白水平等。他们虽然对输血前血红蛋白水平进行了<10 g/dl这样的分层,但对于血红蛋白为7、8或9 g/dl的患者,并不能分析出死亡风险。研究亦未对患者进行清晰的描述,以便于我们分清楚哪些风险与贫血相关,哪些与输血相关。同时,该研究并未进行清晰的亚组分析。上述这些恰恰是能够帮助临床医生做出床旁抉择的重要因素。

  选取比较接受输血和未接受输血的观察性研究进行分析有个致命的缺陷,即,在临床上,接受输血的患者通常较不接受输血的患者病情更重,更易发生致命性的并发症。正如在2010年一项研究中提到的,“当我们研究某种治疗手段的效果时,若开始该治疗的临床指征与临床结局相关,则常常会产生偏倚,因为具有该指征的患者一方面会导致开始治疗,另一方面又与不良结局相关。而我们难以确定,是否其不良结局由治疗所导致。”

  考虑到输血所带来的风险和潜在获益,作为临床医生,我们不应仅根据这项研究的结果来决定是否给患者输血。我们期待未来有更多高质量的研究出现。

心梗相关的拓展阅读:


Here We Go Again—Blood Transfusion Kills Patients?Comment on “Association of Blood Transfusion With Increased Mortality in Myocardial Infarction: A Meta-analysis and Diversity-Adjusted Study Sequential Analysis” 

Do blood transfusions kill more patients with an acute myocardial infarction than anemia? Chatterjee and colleagues1 would have you believe that they do. We remain unconvinced.

In reviewing the study, we first wondered whether the authors asked the right question. As physicians, we believe that profound anemia is life threatening,2 and as a consequence transfusions in many patients are life saving. Therefore, we expected that more nuanced, clinically relevant questions would be addressed.

    

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    2013-01-06 windight
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