Department of Cardiology and Cardiovascular Research Institute Basel (C.P., D.S., L.S., S.M., J.E., I.S., K.W., R.T., J.d.F.d.L., S.O., C.M.)
Department of Anesthesiology, University Hospital Dusseldorf, Germany (G.L.B.).
Circulation. 2018 Mar 20;137(12):1221-1232. doi: 10.1161/CIRCULATIONAHA.117.030114. Epub 2017 Dec 4.
Perioperative myocardial injury (PMI) seems to be a contributor to mortality after noncardiac surgery. Because the vast majority of PMIs are asymptomatic, PMI usually is missed in the absence of systematic screening.
We performed a prospective diagnostic study enrolling consecutive patients undergoing noncardiac surgery who had a planned postoperative stay of ≥24 hours and were considered at increased cardiovascular risk. All patients received a systematic screening using serial measurements of high-sensitivity cardiac troponin T in clinical routine. PMI was defined as an absolute high-sensitivity cardiac troponin T increase of ≥14 ng/L from preoperative to postoperative measurements. Furthermore, mortality was compared among patients with PMI not fulfilling additional criteria (ischemic symptoms, new ECG changes, or imaging evidence of loss of viable myocardium) required for the diagnosis of spontaneous acute myocardial infarction versus those that did.
From 2014 to 2015 we included 2018 consecutive patients undergoing 2546 surgeries. Patients had a median age of 74 years and 42% were women. PMI occurred after 397 of 2546 surgeries (16%; 95% confidence interval, 14%-17%) and was accompanied by typical chest pain in 24 of 397 patients (6%) and any ischemic symptoms in 72 of 397 (18%). Crude 30-day mortality was 8.9% (95% confidence interval [CI], 5.7-12.0) in patients with PMI versus 1.5% (95% CI, 0.9-2.0) in patients without PMI (<0.001). Multivariable regression analysis showed an adjusted hazard ratio of 2.7 (95% CI, 1.5-4.8) for 30-day mortality. The difference was retained at 1 year with mortality rates of 22.5% (95% CI, 17.6-27.4) versus 9.3% (95% CI, 7.9-10.7). Thirty-day mortality was comparable among patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction (280/397, 71%) versus those with at least 1 additional criterion (10.4%; 95% CI, 6.7-15.7, versus 8.7%; 95% CI, 4.2-16.7; =0.684).
PMI is a common complication after noncardiac surgery and, despite early detection during routine clinical screening, is associated with substantial short- and long-term mortality. Mortality seems comparable in patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction versus those patients who do.
URL: https://www.clinicaltrials.gov. Unique identifier: NCT02573532.
围术期心肌损伤（PMI）似乎是导致非心脏手术后死亡的一个因素。由于绝大多数 PMI 是无症状的，因此如果没有系统的筛查，PMI 通常会被遗漏。
我们进行了一项前瞻性诊断研究，纳入了计划术后住院时间≥24 小时且心血管风险增加的连续接受非心脏手术的患者。所有患者均接受了常规临床中使用高敏心肌肌钙蛋白 T 连续测量进行的系统筛查。PMI 定义为术前至术后测量时绝对高敏心肌肌钙蛋白 T 升高≥14ng/L。此外，我们比较了符合自发性急性心肌梗死诊断所需的其他标准（缺血症状、新的心电图改变或有存活心肌丧失的影像学证据）的 PMI 患者与不符合这些标准的患者之间的死亡率。
在 2014 年至 2015 年期间，我们纳入了 2018 名连续接受 2546 次手术的患者。患者的中位年龄为 74 岁，42%为女性。2546 次手术中有 397 次（16%；95%置信区间，14%-17%）发生了 PMI，397 例中有 24 例（6%）伴有典型胸痛，72 例（18%）有任何缺血症状。PMI 患者的 30 天死亡率为 8.9%（95%置信区间，5.7-12.0），无 PMI 患者为 1.5%（95%置信区间，0.9-2.0）（<0.001）。多变量回归分析显示，30 天死亡率的调整危险比为 2.7（95%置信区间，1.5-4.8）。1 年后，死亡率分别为 22.5%（95%置信区间，17.6-27.4）和 9.3%（95%置信区间，7.9-10.7），差异仍保留。在未满足自发性急性心肌梗死的其他任何附加标准的 PMI 患者（397 例中的 280 例，71%）与至少有 1 项附加标准的患者（10.4%；95%置信区间，6.7-15.7 与 8.7%；95%置信区间，4.2-16.7；=0.684）之间，30 天死亡率无差异。
PMI 是非心脏手术后的常见并发症，尽管在常规临床筛查期间早期发现，但仍与短期和长期死亡率显著相关。在未满足自发性急性心肌梗死的其他任何附加标准的 PMI 患者与满足这些标准的患者之间，死亡率似乎无差异。
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