Devereaux P J, Bradley David, Chan Matthew T V, Walsh Mike, Villar Juan Carlos, Polanczyk Carisi Anne, Seligman Beatriz Graeff S, Guyatt Gordon H, Alonso-Coello Pablo, Berwanger Otavio, Heels-Ansdell Diane, Simunovic Nicole, Schünemann Holger, Yusuf Salim
Population Health Research Institute, David Braley Cardiac, Vascular, and Stroke Research Institute, RoomC1-116, Perioperative Medicine and Surgical Research Unit, c/o Hamilton General Hospital, 237 Barton Street East, Hamilton, ON, Canada, L8L2X2.
Open Med. 2011;5(4):e193-200. Epub 2011 Dec 13.
among patients undergoing noncardiac surgery, our objectives were to: (1) determine the feasibility of undertaking a large international cohort study; (2) estimate the current incidence of major perioperative vascular events; (3) compare the observed event rates to the expected event rates according to the Revised Cardiac Risk Index (RCRI); and (4) provide an estimate of the proportion of myocardial infarctions without ischemic symptoms that may go undetected without perioperative troponin monitoring.
An international prospective cohort pilot study.
Patients undergoing noncardiac surgery who were >45 years of age, receiving a general or regional anesthetic, and requiring hospital admission.
Patients had a Roche fourth-generation Elecsys troponin T measurement collected 6 to 12 hours postoperatively and on the first, second, and third days after surgery. Our primary outcome was major vascular events (a composite of vascular death [i.e., death from vascular causes], nonfatal myocardial infarction, nonfatal cardiac arrest, and nonfatal stroke) at 30 days after surgery. Our definition for perioperative myocardial infarction included: (1) an elevated troponin T measurement with at least one of the following defining features: ischemic symptoms, development of pathologic Q waves, ischemic electrocardiogram changes, coronary artery intervention, or cardiac imaging evidence of myocardial infarction; or (2) autopsy findings of acute or healing myocardial infarction.
We recruited 432 patients across 5 hospitals in Canada, China, Italy, Colombia, and Brazil. During the first 30 days after surgery, 6.3% (99% confidence interval 3.9-10.0) of the patients suffered a major vascular event (10 vascular deaths, 16 nonfatal myocardial infarctions, and 1 nonfatal stroke). The observed event rate was increased 6-fold compared with the event rate expected from the RCRI. Of the 18 patients who suffered a myocardial infarction, 12 (66.7%) had no ischemic symptoms to suggest myocardial infarction.
This study suggests that major perioperative vascular events are common, that the RCRI underestimates risk, and that monitoring troponins after surgery can assist physicians to avoid missing myocardial infarction. These results underscore the need for a large international prospective cohort study.
在接受非心脏手术的患者中，我们的目标是：（1）确定开展一项大型国际队列研究的可行性；（2）估计围手术期主要血管事件的当前发生率；（3）根据修订的心脏风险指数（RCRI）将观察到的事件发生率与预期事件发生率进行比较；（4）估计在没有围手术期肌钙蛋白监测的情况下可能未被发现的无缺血症状的心肌梗死比例。
一项国际前瞻性队列试点研究。
年龄大于45岁、接受全身或区域麻醉且需要住院的接受非心脏手术的患者。
患者在术后6至12小时以及术后第一、第二和第三天进行罗氏第四代电化学发光法肌钙蛋白T测量。我们的主要结局是术后30天的主要血管事件（血管死亡[即因血管原因死亡]、非致命性心肌梗死、非致命性心脏骤停和非致命性卒中的综合）。我们对围手术期心肌梗死的定义包括：（1）肌钙蛋白T测量值升高，且具有以下至少一项定义特征：缺血症状、病理性Q波形成、缺血性心电图改变、冠状动脉介入治疗或心肌梗死的心脏影像学证据；或（2）急性或愈合期心肌梗死的尸检结果。
我们在加拿大、中国、意大利、哥伦比亚和巴西的5家医院招募了432名患者。在术后的前30天内，6.3%（99%置信区间3.9 - 10.0）的患者发生了主要血管事件（10例血管死亡、16例非致命性心肌梗死和1例非致命性卒中）。观察到的事件发生率比RCRI预期的事件发生率高出6倍。在18例发生心肌梗死的患者中，12例（66.7%）没有提示心肌梗死的缺血症状。
本研究表明围手术期主要血管事件很常见，RCRI低估了风险，并且术后监测肌钙蛋白可以帮助医生避免漏诊心肌梗死。这些结果强调了开展一项大型国际前瞻性队列研究的必要性。
