非心脏手术后心肌损伤：一项大型国际前瞻性队列研究，确立了诊断标准、特征、预测因素和 30 天结局。

Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.

机构信息

From the Hamilton General Hospital, David Braley Cardiac, Vascular, and Stroke Research Institute, Population Health Research Institute, Hamilton, Ontario, Canada (P.J.D.); and Members of The VISION Writing Group and VISION Investigators, who are listed in appendix 1 and appendix 2, respectively. Population Health Research Institute, Hamilton, Ontario, Canada; Department of Clinical Research, Estudios Clinicos Latino America (ECLA), Rosario, Argentina Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain The Chinese University of Hong Kong, Shatin, N.T., Hong Kong Universidad Autónoma de Bucaramanga and Fundación Cardioinfantil, Colombia St. John's Medical College and Research Institute, Bangalore, India Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada Department of Clinical Epidemiology and Biostatistics and Department of Medicine, McMaster University, Hamilton, Ontario, Canada Hospital General Universitario Gregorio Maranon, Madrid, Spain University of Alberta, Edmonton, Alberta, Canada University of Malaya, Kuala Lampur, Malaysia Research Institute Hcor (Hospital do Coracao), Sao Paulo, Brazil Barts & The London School of Medicine and Dentistry, London, United Kingdom University of Kwazulu-Natal, Durban, South Africa Christian Medical College, Ludhiana, India Universidad PeruanaCayetano Heredia, Lima, Peru The George Institute for Global Health, University of Sydney, Sydney, Australia Population Health Research Institute, Hamilton, Ontario, Canada; University of Kwazulu-Natal, Durban, South Africa Department of Clinical Epidemiology and Biostatistics, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada Hospital de Clinicas de Porto Alegre, Universidade Federal de Rio Grande do Sul, Brazil Jagiellonian University Medical College, Krakow, Poland The Cleveland Clinic, Cleveland, Ohio Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilto

出版信息

Anesthesiology. 2014 Mar;120(3):564-78. doi: 10.1097/ALN.0000000000000113.

DOI:10.1097/ALN.0000000000000113

PMID:24534856

Abstract

BACKGROUND

Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS.

METHODS

In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated "abnormal" laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria.

RESULTS

An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom.

CONCLUSION

Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

摘要

背景

非心脏手术后心肌损伤（MINS）被定义为非心脏手术后发生或术后 30 天内发生的与缺血相关的具有预后意义的心肌损伤。本研究的四个目标是确定 MINS 的诊断标准、特征、预测因素和 30 天结局。

方法

在这项对 15065 名年龄在 45 岁或以上的接受住院非心脏手术的患者进行的国际前瞻性队列研究中，在术后第 3 天内测量肌钙蛋白 T。检测肌钙蛋白 T 水平为 0.04ng/ml 或更高（升高“异常”实验室阈值）的患者是否存在缺血特征（即缺血症状和心电图发现）。排除肌钙蛋白升高非缺血性的患者（例如，脓毒症）。为了建立 MINS 的诊断标准，作者使用 Cox 回归分析，其中因变量为 30 天死亡率（260 例死亡），自变量包括术前变量、围手术期并发症和潜在的 MINS 诊断标准。

结果

非心脏手术后肌钙蛋白升高，无论是否存在缺血特征，均独立预测 30 天死亡率。因此，作者的 MINS 诊断标准是由于心肌缺血导致的肌钙蛋白 T 峰值水平为 0.03ng/ml 或更高。MINS 是 30 天死亡率的独立预测因素（调整后的危险比为 3.87；95%可信区间为 2.96-5.08），且围手术期并发症的人群归因风险最高（34.0%，95%可信区间为 26.6-41.5）。1200 名患者（8.0%）患有 MINS，其中 58.2%的患者不符合心肌梗死的通用定义。只有 15.8%的 MINS 患者出现了缺血症状。