JAMA. 2012 Jun 6;307(21):2295-304. doi: 10.1001/jama.2012.5502.
Of the 200 million adults worldwide who undergo noncardiac surgery each year, more than 1 million will die within 30 days.
To determine the relationship between the peak fourth-generation troponin T (TnT) measurement in the first 3 days after noncardiac surgery and 30-day mortality.
DESIGN, SETTING, AND PARTICIPANTS: A prospective, international cohort study that enrolled patients from August 6, 2007, to January 11, 2011. Eligible patients were aged 45 years and older and required at least an overnight hospital admission after having noncardiac surgery.
Patients' TnT levels were measured 6 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We undertook Cox regression analysis in which the dependent variable was mortality until 30 days after surgery, and the independent variables included 24 preoperative variables. We repeated this analysis, adding the peak TnT measurement during the first 3 postoperative days as an independent variable and used a minimum P value approach to determine if there were TnT thresholds that independently altered patients' risk of death.
A total of 15,133 patients were included in this study. The 30-day mortality rate was 1.9% (95% CI, 1.7%-2.1%). Multivariable analysis demonstrated that peak TnT values of at least 0.02 ng/mL, occurring in 11.6% of patients, were associated with higher 30-day mortality compared with the reference group (peak TnT ≤ 0.01 ng/mL): peak TnT of 0.02 ng/mL (adjusted hazard ratio [aHR], 2.41; 95% CI, 1.33-3.77); 0.03 to 0.29 ng/mL (aHR, 5.00; 95% CI, 3.72-6.76); and 0.30 ng/mL or greater (aHR, 10.48; 95% CI, 6.25-16.62). Patients with a peak TnT value of 0.01 ng/mL or less, 0.02, 0.03-0.29, and 0.30 or greater had 30-day mortality rates of 1.0%, 4.0%, 9.3%, and 16.9%, respectively. Peak TnT measurement added incremental prognostic value to discriminate those likely to die within 30 days for the model with peak TnT measurement vs without (C index = 0.85 vs 0.81; difference, 0.4; 95% CI, 0.2-0.5; P < .001 for difference between C index values). The net reclassification improvement with TnT was 25.0% (P < .001).
Among patients undergoing noncardiac surgery, the peak postoperative TnT measurement during the first 3 days after surgery was significantly associated with 30-day mortality.
每年有超过 2 亿成年人接受非心脏手术，其中超过 100 万人将在术后 30 天内死亡。
确定非心脏手术后前 3 天第四代高敏肌钙蛋白 T（TnT）峰值测量值与 30 天死亡率之间的关系。
设计、地点和参与者：一项前瞻性国际队列研究，于 2007 年 8 月 6 日至 2011 年 1 月 11 日期间纳入患者。纳入标准为年龄 45 岁及以上，且非心脏手术后至少需要住院过夜。
患者的 TnT 水平在手术后 6 至 12 小时以及手术后第 1、2 和 3 天进行测量。我们进行了 Cox 回归分析，因变量为术后 30 天内的死亡率，自变量包括 24 项术前变量。我们重复了这项分析，将前 3 个术后天的 TnT 峰值测量值作为独立变量，并使用最小 P 值法来确定是否存在 TnT 阈值可以独立改变患者的死亡风险。
共有 15133 名患者纳入本研究。30 天死亡率为 1.9%（95%CI，1.7%2.1%）。多变量分析表明，与参考组（TnT 峰值≤0.01ng/ml）相比，至少有 11.6%的患者出现 0.02ng/ml 或更高的 TnT 峰值，与 30 天死亡率更高相关：0.02ng/ml（调整后的危险比[aHR]，2.41；95%CI，1.333.77）；0.030.29ng/ml（aHR，5.00；95%CI，3.726.76）；和 0.30ng/ml 或更高（aHR，10.48；95%CI，6.2516.62）。TnT 峰值为 0.01ng/ml 或更低、0.02、0.030.29 和 0.30ng/ml 或更高的患者 30 天死亡率分别为 1.0%、4.0%、9.3%和 16.9%。与不包括 TnT 峰值测量值的模型相比（C 指数=0.81），纳入 TnT 峰值测量值的模型对死亡风险的区分能力更高（C 指数=0.85；差异，0.4；95%CI，0.2~0.5；P<.001）。TnT 检测的净重新分类改善为 25.0%（P<.001）。
在接受非心脏手术的患者中，术后前 3 天的 TnT 峰值测量值与 30 天死亡率显著相关。
