Martinez Elizabeth A, Nass Caitlin M, Jermyn Roland M, Rosenbaum Stanley H, Akhtar Shamsuddin, Chan Daniel W, Malkus Herbert, Weiss James L, Fleisher Lee A
The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
J Cardiothorac Vasc Anesth. 2005 Oct;19(5):577-82. doi: 10.1053/j.jvca.2005.07.002.
Several studies suggest that cardiac troponin-I (cTn-I) is a more sensitive indicator of cardiac injury compared with other biochemical markers of injury, but the strategy with the highest diagnostic yield (true positive and true negative) for perioperative surveillance is unknown. The authors undertook a prospective evaluation of the perioperative incidence of myocardial infarction (MI) and evaluated surveillance strategies for the diagnosis of MI.
Prospective, cohort study.
Two university hospitals.
Four hundred sixty-seven high-risk patients requiring noncardiac surgery.
None.
The diagnosis of myocardial injury was determined by cardiac protein markers combined with either postoperative changes on 12-lead electrocardiography or 1 of 3 clinical symptoms consistent with MI (chest pain, dyspnea, requirement for hemodynamic support). A receiver operating characteristic curve evaluating troponin in the diagnosis of MI revealed a value of 2.6 ng/mL as having the highest sensitivity and specificity. The sensitivity and specificity of cTn-I value > or =2.6 ng/mL, troponin > or =1.5 ng/mL, total creatine kinase (CK) > or =170 IU/L with MB > or =5%, and CK-MB > or =8 ng/mL were compared. Surveillance strategies were determined on a subset of patients (n = 257). The incidence of MI was 9.0% by cTn-I > or =2.6 ng/mL criteria, 19% by cTn-I > or =1.5 ng/mL, 13% by CK-MB mass, and 2.8% by CK-MB%. The specificity of cTn-I > or =2.6 ng/mL as an indicator of MI was 98%, and its positive predictive value (PPV) was 85%. Cardiac troponin-I > or =2.6 ng/mL had equal specificity but greater PPV than the cTn-I > or =1.5 ng/mL (specificity 98% and PPV 79%). If surveillance of cTn-I > or =2.6 ng/mL was used to detect MI, then the strategy with the highest diagnostic yield was surveillance on postoperative days 1, 2, and 3.
Perioperative cardiac injury continues to occur frequently after noncardiac surgery, as detected by cTn-I. Serial monitoring of cardiac troponin-I on postoperative days 1, 2, and 3 provides the strategy with the highest diagnostic yield for surveillance of MI.
多项研究表明，与其他损伤生化标志物相比，心肌肌钙蛋白I（cTn-I）是心肌损伤更敏感的指标，但围手术期监测中诊断率（真阳性和真阴性）最高的策略尚不清楚。作者对围手术期心肌梗死（MI）的发生率进行了前瞻性评估，并评估了MI的监测策略。
前瞻性队列研究。
两家大学医院。
467例需要进行非心脏手术的高危患者。
无。
心肌损伤的诊断通过心脏蛋白标志物结合术后12导联心电图变化或与MI一致的3种临床症状之一（胸痛、呼吸困难、需要血流动力学支持）来确定。评估肌钙蛋白在MI诊断中的受试者工作特征曲线显示，2.6 ng/mL具有最高的敏感性和特异性。比较了cTn-I值≥2.6 ng/mL、肌钙蛋白≥1.5 ng/mL、总肌酸激酶（CK）≥170 IU/L且MB≥5%以及CK-MB≥8 ng/mL的敏感性和特异性。在一部分患者（n = 257）中确定监测策略。根据cTn-I≥2.6 ng/mL标准，MI发生率为9.0%；根据cTn-I≥1.5 ng/mL为19%；根据CK-MB质量为13%；根据CK-MB%为2.8%。cTn-I≥2.6 ng/mL作为MI指标的特异性为98%，其阳性预测值（PPV）为85%。心脏肌钙蛋白I≥2.6 ng/mL具有相同的特异性，但PPV高于cTn-I≥1.5 ng/mL（特异性98%，PPV 79%）。如果使用cTn-I≥2.6 ng/mL监测来检测MI，那么诊断率最高的策略是在术后第1、2和3天进行监测。
通过cTn-I检测发现，非心脏手术后围手术期心脏损伤仍频繁发生。术后第1、2和3天对心脏肌钙蛋白I进行连续监测为MI监测提供了诊断率最高的策略。
