Hernández-Leiva Edgar, Dennis Rodolfo, Isaza Daniel, Umaña Juan Pablo
Department of Cardiology, Section of Cardiovascular Critical Care, Instituto de Cardiología-Fundación Cardioinfantil, Universidad del Rosario, Bogotá, Colombia.
J Cardiothorac Surg. 2013 Jul 5;8:170. doi: 10.1186/1749-8090-8-170.
Risk stratification in cardiac surgery significantly impacts outcome. This study seeks to define whether there is an independent association between the preoperative serum level of hemoglobin (Hb), leukocyte count (LEUCO), high sensitivity C-reactive protein (hsCRP), or B-type natriuretic peptide (BNP) and postoperative morbidity and mortality in cardiac surgery.
Prospective, analytic cohort study, with 554 adult patients undergoing cardiac surgery in a tertiary cardiovascular hospital and followed up for 12 months. The cohort was distributed according to preoperative values of Hb, LEUCO, hsCRP, and BNP in independent quintiles for each of these variables.
After adjustment for all covariates, a significant association was found between elevated preoperative BNP and the occurrence of low postoperative cardiac output (OR 3.46, 95% CI 1.53-7.80, p = 0.003) or postoperative atrial fibrillation (OR 3.8, 95% CI 1.45-10.38). For the combined outcome (death/acute coronary syndrome/rehospitalization within 12 months), we observed an OR of 1.93 (95% CI 1.00-3.74). An interaction was found between BNP level and the presence or absence of diabetes mellitus. The OR for non-diabetics was 1.26 (95% CI 0.61-2.60) and for diabetics was 18.82 (95% CI 16.2-20.5). Preoperative Hb was also significantly and independently associated with the occurrence of postoperative low cardiac output (OR 0.33, 95% CI 0.13-0.81, p = 0.016). Both Hb and BNP were significantly associated with the lengths of intensive care unit and hospital stays and the number of transfused red blood cells (p < 0.002). Inflammatory markers, although associated with adverse outcomes, lost statistical significance when adjusted for covariates.
High preoperative BNP or low Hb shows an association of independent risk with postoperative outcomes, and their measurement could help to stratify surgical risk. The ability to predict the onset of atrial fibrillation or postoperative low cardiac output has important clinical implications. Our results open the possibility of designing studies that incorporate BNP measurement as a routine part of preoperative evaluation, and this strategy could improve upon the standard evaluation in terms of reducing adverse postoperative events.
心脏手术中的风险分层对手术结果有重大影响。本研究旨在确定术前血清血红蛋白（Hb）水平、白细胞计数（LEUCO）、高敏C反应蛋白（hsCRP）或B型利钠肽（BNP）与心脏手术后的发病率和死亡率之间是否存在独立关联。
前瞻性分析队列研究，纳入了一家三级心血管医院的554例接受心脏手术的成年患者，并进行了12个月的随访。根据这些变量各自独立的五分位数，将队列按照术前Hb、LEUCO、hsCRP和BNP的值进行分组。
在对所有协变量进行调整后，发现术前BNP升高与术后低心输出量的发生之间存在显著关联（比值比[OR] 3.46，95%置信区间[CI] 1.53 - 7.80，p = 0.003）或术后房颤（OR 3.8，95% CI 1.45 - 10.38）。对于综合结局（12个月内死亡/急性冠状动脉综合征/再次住院），我们观察到的OR为1.93（95% CI 1.00 - 3.74）。发现BNP水平与糖尿病的有无之间存在交互作用。非糖尿病患者的OR为1.26（95% CI 0.61 - 2.60），糖尿病患者的OR为18.82（95% CI 16.2 - 20.5）。术前Hb也与术后低心输出量的发生显著且独立相关（OR 0.33，95% CI 0.13 - 0.81，p = 0.016）。Hb和BNP均与重症监护病房住院时间、住院时间以及输注红细胞的数量显著相关（p < 0.002）。炎症标志物虽然与不良结局相关，但在调整协变量后失去了统计学意义。
术前高BNP或低Hb显示出与术后结局的独立风险关联，对它们的检测有助于对手术风险进行分层。预测房颤或术后低心输出量发作的能力具有重要的临床意义。我们的结果为设计将BNP检测纳入术前评估常规部分的研究开辟了可能性，并且这种策略在减少术后不良事件方面可能会改进标准评估。
