丹麦哥本哈根大学医院Jesper Kjaergaard团队研究了心脏骤停后昏迷幸存者的不同血压目标对患者预后的影响。这一研究成果于2022年8月27日发表在《新英格兰医学杂志》上。

支持选择血压目标来治疗接受重症监护的院外心脏骤停昏迷幸存者的证据有限。

在一项2乘2析因设计的双盲随机试验中，研究组评估了院外心脏骤停后被复苏的昏迷成人的平均动脉血压目标为63 mmHg与77 mmHg对预后的影响，患者也被分配到两个氧目标中的一个（单独报告）。主要结局是90天内全因死亡或出院，脑功能分类（CPC）为3或4（范围为0至5，更高的分类表示更严重的残疾；3或4表示严重残疾或昏迷）。次要结果包括48小时的神经元特异性烯醇化酶水平、全因死亡、3个月时蒙特利尔认知评估（0-30分，分数越高表示认知能力越好）和改良Rankin量表（0-6分，分数高表示残疾程度越高）评分，以及3个月后的CPC。

共有789名患者被纳入分析（高目标组393名，低目标组396名）。高目标组中有133名患者（34%）发生主要结局事件，低目标组中有127名患者（32%），危险比为1.08，组间差异不显著。90天时，高目标组中有122名患者（31%）死亡，低目标组中有114名（29%）死亡，危险比为1.13。高目标组和低目标组的中位CPC均为1；相应的修正Rankin量表中位数得分分别为1，相应的蒙特利尔认知评估中位数得分分别为27和26。两组48小时的神经元特异性烯醇化酶的中值水平也相似。两组之间发生不良事件的患者百分比无显著差异。

研究结果表明，对于从心脏骤停中复苏的患者，将平均动脉压定为63 mmHg或77 mmHg并不会导致死亡或严重残疾或昏迷的患者百分比显著不同。

附：英文原文

Title: Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest

Author: Jesper Kjaergaard, M.D., D.M.Sc.,, Jacob E. Mller, M.D., D.M.Sc.,, Henrik Schmidt, M.D., D.M.Sc.,, Johannes Grand, M.D., Ph.D.,, Simon Mlstrm, M.D.,, Britt Borregaard, R.N., Ph.D.,, Sren Ven, M.D.,, Laura Sarkisian, M.D., Ph.D.,, Dmitry Mamaev, M.D.,, Lisette O. Jensen, M.D., D.M.Sc.,, Benjamin Nyholm, M.D.,, Dan E. Hfsten, M.D., Ph.D.,, Jakob Josiassen, M.D., Ph.D.,, Jakob H. Thomsen, M.D., Ph.D.,, Jens J. Thune, M.D., Ph.D.,, Laust E.R. Obling, M.D.,, Matias G. Lindholm, M.D., Ph.D.,, Martin Frydland, M.D., Ph.D.,, Martin A.S. Meyer, M.D.,, Matilde Winther-Jensen, Ph.D.,, Rasmus P. Beske, M.D.,, Ruth Frikke-Schmidt, M.D., D.M.Sc.,, Sebastian Wiberg, M.D., Ph.D.,, Sren Boesgaard, M.D., D.M.Sc.,, Sren A. Madsen, M.D.,, Vibeke L. Jrgensen, M.D., Ph.D.,, and Christian Hassager, M.D., D.M.Sc.

Issue&Volume: 2022-08-27

Abstract:

Background

Evidence to support the choice of blood-pressure targets for the treatment of comatose survivors of out-of-hospital cardiac arrest who are receiving intensive care is limited.

Methods

In a double-blind, randomized trial with a 2-by-2 factorial design, we evaluated a mean arterial blood-pressure target of 63 mm Hg as compared with 77 mm Hg in comatose adults who had been resuscitated after an out-of-hospital cardiac arrest of presumed cardiac cause; patients were also assigned to one of two oxygen targets (reported separately). The primary outcome was a composite of death from any cause or hospital discharge with a Cerebral Performance Category (CPC) of 3 or 4 within 90 days (range, 0 to 5, with higher categories indicating more severe disability; a category of 3 or 4 indicates severe disability or coma). Secondary outcomes included neuron-specific enolase levels at 48 hours, death from any cause, scores on the Montreal Cognitive Assessment (range, 0 to 30, with higher scores indicating better cognitive ability) and the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at 3 months, and the CPC at 3 months.

Results

A total of 789 patients were included in the analysis (393 in the high-target group and 396 in the low-target group). A primary-outcome event occurred in 133 patients (34%) in the high-target group and in 127 patients (32%) in the low-target group (hazard ratio, 1.08; 95% confidence interval [CI], 0.84 to 1.37; P=0.56). At 90 days, 122 patients (31%) in the high-target group and 114 patients (29%) in the low-target group had died (hazard ratio, 1.13; 95% CI, 0.88 to 1.46). The median CPC was 1 (interquartile range, 1 to 5) in both the high-target group and the low-target group; the corresponding median modified Rankin scale scores were 1 (interquartile range, 0 to 6) and 1 (interquartile range, 0 to 6), and the corresponding median Montreal Cognitive Assessment scores were 27 (interquartile range, 24 to 29) and 26 (interquartile range, 24 to 29). The median neuron-specific enolase level at 48 hours was also similar in the two groups. The percentages of patients with adverse events did not differ significantly between the groups.

Conclusions

Targeting a mean arterial blood pressure of 77 mm Hg or 63 mm Hg in patients who had been resuscitated from cardiac arrest did not result in significantly different percentages of patients dying or having severe disability or coma.

DOI: 10.1056/NEJMoa2208687

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa2208687