术前凝血和纤溶功能改变与非心脏手术后心肌损伤有关。

Altered preoperative coagulation and fibrinolysis are associated with myocardial injury after non-cardiac surgery.

机构信息

Department of Intensive Care and Perioperative Medicine.

Department of Medicine.

出版信息

Br J Anaesth. 2017 May 1;118(5):713-719. doi: 10.1093/bja/aex081.

DOI:10.1093/bja/aex081

PMID:28486646

Abstract

BACKGROUND

Myocardial injury after non-cardiac surgery (MINS), a complication with unclear pathogenesis, occurs within the first 30 days after surgery and worsens prognosis. Hypercoagulability induced by surgery might contribute to plaque rupture, with subsequent thrombosis and myocardial injury. This study assessed haemostatic markers before surgery and evaluated their association with MINS.

METHODS

This is a substudy of VISION, a prospective cohort study of perioperative cardiovascular events. Of 475 consecutive vascular surgery patients, 47 (9.9%) developed MINS, defined as postoperative high-sensitivity troponin ≥50 ng litre -1 , with ≥20% elevation from the preoperative concentration. The control group consisted of 84 non-MINS patients matched for patient characteristics and co-morbidities. The following preoperative markers of hypercoagulability and fibrinolysis were measured: antithrombin, factor VIII activity, von Willebrand factor concentration and activity, fibrinogen, D-dimer, plasmin-antiplasmin complex, and tissue plasminogen activator. Moreover, C-reactive protein and CD40L concentrations were measured to assess inflammatory activity.

RESULTS

Patients with MINS compared with the non-MINS group had a significantly higher concentration of factor VIII (186 vs 155%, P =0.006), von Willebrand factor activity (223 vs 160%, P <0.001), von Willebrand factor concentration (317 vs 237%, P =0.02), concentrations of fibrinogen (5.6 vs 4.2 g litre -1 , P =0.03), D-dimer (1680.0 vs 1090.0 ng ml -1 , P =0.04), plasmin-antiplasmin complex (747 vs 512 ng ml -1 , P =0.002) and C-reactive protein (10 vs 4.5 mg litre -1 , P =0.02) but not antithrombin (95 vs 94%, P =0.89), tissue plasminogen activator (11 vs 9.7 ng ml -1 , P =0.06) and CD40L (8790 vs 8580 pg ml -1 , P =0.73).

CONCLUSIONS

Preoperative elevation of blood markers of hypercoagulability in patients undergoing vascular surgery is associated with a higher risk of MINS.

CLINICAL TRIAL REGISTRATION

NCT00512109.

摘要

背景

非心脏手术后心肌损伤（MINS）是一种发病机制尚不清楚的并发症，发生在手术后 30 天内，且会使预后恶化。手术引起的高凝状态可能导致斑块破裂，随后发生血栓和心肌损伤。本研究评估了手术前的止血标志物，并评估了其与 MINS 的相关性。

方法

这是一项前瞻性血管手术围术期心血管事件研究（VISION）的子研究。在 475 例连续血管手术患者中，有 47 例（9.9%）发生 MINS，定义为术后高敏肌钙蛋白 ≥50ng/L，且较术前浓度升高≥20%。对照组由 84 例非 MINS 患者组成，这些患者的患者特征和合并症相匹配。测量了以下手术前的高凝和纤溶标志物：抗凝血酶、VIII 因子活性、血管性血友病因子浓度和活性、纤维蛋白原、D-二聚体、纤溶酶-抗纤溶酶复合物和组织型纤溶酶原激活物。此外，还测量了 C 反应蛋白和 CD40L 浓度以评估炎症活性。

结果

与非 MINS 组相比，MINS 患者的 VIII 因子浓度（186%比 155%，P=0.006）、血管性血友病因子活性（223%比 160%，P<0.001）、血管性血友病因子浓度（317%比 237%，P=0.02）、纤维蛋白原浓度（5.6g/L 比 4.2g/L，P=0.03）、D-二聚体浓度（1680.0ng/ml 比 1090.0ng/ml，P=0.04）、纤溶酶-抗纤溶酶复合物浓度（747ng/ml 比 512ng/ml，P=0.002）和 C 反应蛋白浓度（10mg/L 比 4.5mg/L，P=0.02）较高，但抗凝血酶（95%比 94%，P=0.89）、组织型纤溶酶原激活物（11ng/ml 比 9.7ng/ml，P=0.06）和 CD40L（8790pg/ml 比 8580pg/ml，P=0.73）无差异。