血管手术后的心肌梗死：长时间应激诱导的ST段压低型缺血的作用。

Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST depression-type ischemia.

作者信息

Landesberg G, Mosseri M, Zahger D, Wolf Y, Perouansky M, Anner H, Drenger B, Hasin Y, Berlatzky Y, Weissman C

机构信息

Department of Anesthesiology and Critical Care Medicine, Hadassah University Hospital, Ein-Kerem, Jerusalem, Israel.

出版信息

J Am Coll Cardiol. 2001 Jun 1;37(7):1839-45. doi: 10.1016/s0735-1097(01)01265-7.

DOI:10.1016/s0735-1097(01)01265-7

PMID:11401120

Abstract

OBJECTIVES

The goal of this study was to investigate the nature of the association between silent ischemia and postoperative myocardial infarction (PMI).

BACKGROUND

Silent ischemia predicts cardiac morbidity and mortality in both ambulatory and postoperative patients. Whether silent stress-induced ischemia is merely a marker of extensive coronary artery disease or has a closer association with infarction has not been determined.

METHODS

In 185 consecutive patients undergoing vascular surgery, we correlated ischemia duration, as detected on a continuous 12-lead ST-trend monitoring during the period 48 h to 72 h after surgery, with cardiac troponin-I (cTn-I) measured in the first three postoperative days and with postoperative cardiac outcome. Postoperative myocardial infarction was defined as cTn-I >3.1 ng/ml accompanied by either typical symptoms or new ischemic electrocardiogram (ECG) findings.

RESULTS

During 11,132 patient-hours of monitoring, 38 patients (20.5%) had 66 transient ischemic events, all but one denoted by ST-segment depression. Twelve patients (6.5%) sustained PMI; one of those patients died. All infarctions were non-Q-wave and were detected by a rise in cTn-I during or immediately after prolonged, ST depression-type ischemia. The average duration ofischemia in patients with PMI was 226+/-164 min (range: 29 to 625), compared with 38+/-26 min (p = 0.0000) in 26 patients with ischemia but not infarction. Peak cTn-I strongly correlated with the longest, as well as cumulative, ischemia duration (r = 0.83 and r = 0.78, respectively). Ischemic ECG changes were completely reversible in all but one patient who had persistent new T wave inversion. All ischemic events culminating in PMI were preceded by an increase in heart rate (delta heart rate = 32+/-15 beats/min), and most (67%) of them began at the end of surgery and emergence from anesthesia.

CONCLUSIONS

Prolonged, ST depression-type ischemia progresses to MI and is strongly associated with the majority of cardiac complications after vascular surgery.

摘要

目的

本研究的目的是调查无症状性心肌缺血与术后心肌梗死（PMI）之间关联的性质。

背景

无症状性心肌缺血可预测门诊患者和术后患者的心脏发病率和死亡率。无症状性应激诱导的心肌缺血仅仅是广泛冠状动脉疾病的一个标志物，还是与梗死有更密切的关联，目前尚未确定。

方法

在185例连续接受血管手术的患者中，我们将术后48小时至72小时期间通过连续12导联ST段趋势监测检测到的缺血持续时间，与术后前三天测量的心肌肌钙蛋白I（cTn-I）以及术后心脏结局进行关联分析。术后心肌梗死定义为cTn-I>3.1 ng/ml，伴有典型症状或新的缺血性心电图（ECG）表现。

结果

在11132患者小时的监测期间，38例患者（20.5%）发生了66次短暂性缺血事件，除1例以外均表现为ST段压低。12例患者（6.5%）发生了PMI；其中1例患者死亡。所有梗死均为非Q波梗死，通过长时间ST段压低型缺血期间或之后cTn-I升高检测到。发生PMI的患者缺血平均持续时间为226±164分钟（范围：29至625分钟），相比之下，26例有缺血但未发生梗死的患者缺血持续时间为38±26分钟（p = 0.0000）。cTn-I峰值与最长缺血持续时间以及累积缺血持续时间密切相关（分别为r = 0.83和r = 0.78）。除1例患者持续出现新的T波倒置外，所有缺血性ECG改变均可完全逆转。所有最终导致PMI的缺血事件之前均有心率增加（心率变化=32±15次/分钟），并且其中大多数（67%）在手术结束和麻醉苏醒时开始。