Foucrier Arnaud, Rodseth Reitze, Aissaoui Mohamed, Ibanes Cristina, Goarin Jean-Pierre, Landais Paul, Coriat Pierre, Le Manach Yannick
From the *Department of Anesthesiology and Critical Care, University Pierre et Marie-Curie-Paris 6, Assistance Publique-Hôpitaux de Paris, Paris, France; †Hospital Pitié-Salpétrière, Paris, France; ‡Department of Anaesthesia, Perioperative Research Group, University of KwaZulu-Natal, Pietermarizburg, South Africa; §The Perioperative Research Group, Population Health Research Institute, Hamilton, Ontario, Canada; ∥Biostatistical and Clinical Epidemiology Department, Faculty of Medicine, Nimes University Hospital, Montpellier 1 University, Montpellier, France; and ¶Departments of Anesthesia & Clinical Epidemiology and Biostatistics, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University and Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Perioperative Medicine and Surgical Research Unit, Hamilton, Ontario, Canada.
Anesth Analg. 2014 Nov;119(5):1053-63. doi: 10.1213/ANE.0000000000000302.
Acute cardiac events are a frequent cause of morbidity after vascular surgery. The impact of early evidence-based treatment for patients with an acute cardiac event after vascular surgery on long-term postoperative outcomes has not been extensively studied. We hypothesized that providing appropriate evidence-based treatment to patients with elevated postoperative cardiac troponin levels may limit long-term mortality.
We conducted a study of 667 consecutive major vascular surgery patients with an elevated postoperative troponin I level. We then determined which of these patients received medical therapy as per the 2007 American College of Cardiology/American Heart Association recommendations for the medical management of patients with chronic stable angina. All patients with troponin elevation were then matched with 2 control patients without postoperative troponin elevation. Matching was done using logistic regression and nearest-neighbor matching methods. The primary study end point was 12 months survival without a major cardiac event (i.e., death, myocardial infarction, coronary revascularization, or pulmonary edema requiring hospitalization).
Therapy was intensified in 43 of 66 patients (65%) who suffered a troponin I elevation after surgery. Patients with a troponin I elevation not receiving intensified cardiovascular treatment had a hazard ratio (HR) of 1.77 (95% confidence interval (CI), 1.13-2.42; P = 0.004) for the primary study outcome as compared with the control group. In contrast, patients with a troponin I elevation who received intensified cardiovascular treatment had an HR of 0.63 (95% CI, 0.10-1.19; P = 0.45) for the primary outcome as compared with the control group. Patients with a troponin I elevation not receiving treatment intensification likely were at higher risk for a major cardiac event (HR, 2.80; 95% CI, 1.05-24.2; P = 0.04) compared with patients who did receive treatment intensification.
The main finding of this study was that in patients with elevated troponin I levels after noncardiac surgery, long-term adverse cardiac outcomes may likely be improved by following evidence-based recommendations for the medical management of acute coronary syndromes.
急性心脏事件是血管手术后发病的常见原因。血管手术后急性心脏事件患者早期循证治疗对术后长期预后的影响尚未得到广泛研究。我们假设，对术后心肌肌钙蛋白水平升高的患者提供适当的循证治疗可能会降低长期死亡率。
我们对667例术后肌钙蛋白I水平升高的连续性大血管手术患者进行了一项研究。然后我们确定这些患者中哪些按照2007年美国心脏病学会/美国心脏协会关于慢性稳定型心绞痛患者药物治疗的建议接受了药物治疗。然后将所有肌钙蛋白升高的患者与2例术后肌钙蛋白未升高的对照患者进行匹配。匹配采用逻辑回归和最近邻匹配方法。主要研究终点是12个月无重大心脏事件存活（即死亡、心肌梗死、冠状动脉血运重建或需要住院治疗的肺水肿）。
66例术后肌钙蛋白I升高的患者中有43例（65%）强化了治疗。与对照组相比，术后肌钙蛋白I升高但未接受强化心血管治疗的患者主要研究结局的风险比（HR）为1.77（95%置信区间[CI]，1.13 - 2.42；P = 0.004）。相比之下，与对照组相比，术后肌钙蛋白I升高且接受强化心血管治疗的患者主要结局的HR为0.63（95% CI，0.10 - 1.19；P = 0.45）。与接受治疗强化的患者相比，术后肌钙蛋白I升高但未接受治疗强化的患者发生重大心脏事件的风险可能更高（HR，2.80；95% CI，1.05 - 24.2；P = 0.04）。
本研究的主要发现是，在非心脏手术后肌钙蛋白I水平升高的患者中，遵循急性冠状动脉综合征药物治疗的循证建议可能会改善长期不良心脏结局。
