Bjessmo S, Svenarud P, Tran P-K
Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
Thorac Cardiovasc Surg. 2009 Apr;57(3):148-52. doi: 10.1055/s-2008-1039217. Epub 2009 Mar 27.
Patients with acute coronary syndrome have an increased risk of cardiac death or myocardial infarction after urgent coronary artery bypass surgery (CABG). Symptoms and signs of ongoing ischemia, such as elevated cardiac troponin T and angina at rest at the time of the operation identify patients at particular risk of early death, but the impact of these parameters on long-term survival is poorly investigated.
Two hundred patients, 100 with acute coronary syndrome and 100 with stable angina pectoris, underwent primary isolated CABG. Troponin T levels were assayed immediately before the operation and at 64 hours after the aortic cross-clamp had been removed. The severity of the patients' unstable symptoms was classified according to Braunwald. Early outcome and long-term survival were analyzed.
Among the unstable patients 3 deaths occurred within 30 days of the operation, and there were 12 late deaths. In the control group there were no early and 19 late deaths. The patients were followed up for 6.5 years (0-7.7 years), a total of 1 294 patient years. The cumulative long-term survival was 85 % for the unstable and 81 % for the stable patients ( P = 0.75). Freedom from cardiac death was 92 % in unstable and 94 % in stable patients. Five unstable and one of the stable patients suffered postoperative myocardial infarction ( P = 0.01). A troponin T level > 0.1 microg/L immediately prior to the operation was associated with an increased need for postoperative pharmacological inotropic support ( P < 0.001) and intra-aortic balloon counterpulsation ( P = 0.004). Symptoms and signs of ongoing ischemia (angina at rest and elevated troponin T immediately prior to the operation) had no predictive value for long-term survival.
In patients with acute coronary syndrome, parameters such as elevated troponin T and angina at rest herald an increased risk of postoperative myocardial infarction and indicate the need for pharmacological and mechanical inotropic support but have no bearing on long-term survival.
急性冠状动脉综合征患者在急诊冠状动脉旁路移植术（CABG）后发生心源性死亡或心肌梗死的风险增加。手术时持续缺血的症状和体征，如心肌肌钙蛋白T升高和静息性心绞痛，可识别出具有早期死亡特殊风险的患者，但这些参数对长期生存的影响研究较少。
200例患者，100例为急性冠状动脉综合征患者，100例为稳定型心绞痛患者，接受了初次单纯CABG。在手术前及主动脉阻断钳移除后64小时测定肌钙蛋白T水平。根据Braunwald对患者不稳定症状的严重程度进行分类。分析早期结局和长期生存情况。
不稳定患者中有3例在术后30天内死亡，12例为晚期死亡。对照组无早期死亡，19例为晚期死亡。患者随访6.5年（0 - 7.7年），共1294患者年。不稳定患者的累积长期生存率为85%，稳定患者为81%（P = 0.75）。不稳定患者的心源性死亡自由度为92%，稳定患者为94%。5例不稳定患者和1例稳定患者发生术后心肌梗死（P = 0.01）。术前肌钙蛋白T水平>0.1μg/L与术后药物性心肌收缩力支持需求增加（P < 0.001）和主动脉内球囊反搏需求增加（P = 0.004）相关。持续缺血的症状和体征（静息性心绞痛和术前肌钙蛋白T升高）对长期生存无预测价值。
在急性冠状动脉综合征患者中，如肌钙蛋白T升高和静息性心绞痛等参数预示着术后心肌梗死风险增加，并表明需要药物和机械性心肌收缩力支持，但与长期生存无关。
