经体外循环心脏手术后患者的高敏肌钙蛋白与术后 30 天和 12 个月全因死亡率的关系。

Postoperative High-Sensitivity Troponin and Its Association With 30-Day and 12-Month, All-Cause Mortality in Patients Undergoing On-Pump Cardiac Surgery.

机构信息

From the *Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel University Hospital, Basel, Switzerland; †Division of Cardiac Surgery, Basel University Hospital, Basel, Switzerland; and ‡Basel University Medical School, Basel, Switzerland.

出版信息

Anesth Analg. 2017 Oct;125(4):1110-1117. doi: 10.1213/ANE.0000000000002023.

DOI:10.1213/ANE.0000000000002023

PMID:28537984

Abstract

BACKGROUND

Troponin T is a predictor of cardiac morbidity and mortality after cardiac surgery with most data examining fourth generational troponin T assays. We hypothesize that postoperative high-sensitivity troponin T (hsTnT) measured in increments of the upper limit of the norm independently predicts 30-day all-cause mortality.

METHODS

We included consecutive patients undergoing on-pump cardiac surgery from February 2010 to March 2012 in a prospective cohort that measured hsTnT at 0600 of the first and second postoperative day. Our primary end point was 30-day, all-cause mortality. The secondary end point was 12-month, all-cause mortality in patients surviving the first 30 days. We divided hsTnT into 5 predetermined categorizes based on the upper limit of the norm (ULN). We used Cox regression to examine an association of hsTnT independent of the EuroSCORE II at both 30 days as well as at 12 months in patients surviving the first 30 days. We assessed the area under the receiver operating characteristics curve and the net reassignment improvement for examining the benefit of adding of hsTnT to the EuroSCORE II for prognostication and restratification of 30-day, all-cause mortality.

RESULTS

We included 1122 of 1155 eligible patients (75% male; mean age 66 ± 11 years). We observed 58 (5.2%) deaths at 30 days and another 35 (3.4%) deaths at 12 months in patients surviving 30 days. HsTnT categorized by ULN exhibited a graded response for the mortality. Furthermore, hsTnT remained an independent predictor of all-cause mortality at 30 days (adjusted hazard ratio 1.019 [1.014-1.024] per 10-fold increase in ULN) as well as at 12 months (adjusted hazard ratio 1.019 [1.007-1.032]) in patients surviving the first 30 days. The addition of hsTnT to the EuroSCORE II significantly increased the area under the receiver operating characteristics curve (area under curve: 0.816 [95% confidence interval, 0.754-0.878] versus area under curve: 0.870 [95% confidence interval, 0.822-0.917], respectively; P = .012). Finally, adding hsTnT to the EuroSCORE II improved restratification by the net reassignment improvement, primarily by improving rule-out of events.

CONCLUSIONS

This analysis suggests that, similar to previous assays, higher postoperative concentrations of hsTnT are independently associated with all-cause mortality in patients undergoing on-pump cardiac surgery.

摘要

背景

肌钙蛋白 T 是心脏手术后心源性发病率和死亡率的预测因子，大多数数据均检查了第四代肌钙蛋白 T 检测。我们假设，在手术后以正常上限的倍数测量的术后高敏肌钙蛋白 T（hsTnT）可独立预测 30 天全因死亡率。

方法

我们纳入了 2010 年 2 月至 2012 年 3 月期间接受体外循环心脏手术的连续患者，前瞻性队列在术后第 1 天和第 2 天 0600 时测量 hsTnT。我们的主要终点是 30 天全因死亡率。次要终点是在第 30 天存活的患者的 12 个月全因死亡率。我们根据正常上限（ULN）将 hsTnT 分为 5 个预定类别。我们使用 Cox 回归检查 hsTnT 与 EuroSCORE II 之间的关联，在第 30 天和第 12 个月（在第 30 天存活的患者中）的独立相关性。我们评估了接受者操作特征曲线下的面积和净再分配改善，以检查 hsTnT 添加到 EuroSCORE II 中对预后和 30 天全因死亡率的重新分层的益处。

结果

我们纳入了 1155 名合格患者中的 1122 名（75％为男性；平均年龄 66±11 岁）。我们观察到在第 30 天有 58 例（5.2％）死亡，在第 30 天存活的患者中又有 35 例（3.4％）死亡。根据 ULN 分类的 hsTnT 表现出死亡率的分级反应。此外，hsTnT 在第 30 天（调整后的危险比 1.019 [1.014-1.024]每增加 10 倍 ULN）和第 12 个月（调整后的危险比 1.019 [1.007-1.032]）仍然是全因死亡率的独立预测因子。hsTnT 与 EuroSCORE II 相加显著增加了接受者操作特征曲线下的面积（曲线下面积：0.816 [95％置信区间，0.754-0.878]与曲线下面积：0.870 [95％置信区间，0.822-0.917]，分别为；P=0.012）。最后，hsTnT 与 EuroSCORE II 的添加通过净再分配改善提高了重新分层，主要是通过排除事件来改善。