William Harvey Research Institute, Queen Mary University of London, London, UK; University College London Hospital, London, UK.
William Harvey Research Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK.
Br J Anaesth. 2019 Feb;122(2):188-197. doi: 10.1016/j.bja.2018.10.060. Epub 2018 Dec 17.
The aetiology of perioperative myocardial injury is poorly understood and not clearly linked to pre-existing cardiovascular disease. We hypothesised that loss of cardioprotective vagal tone [defined by impaired heart rate recovery ≤12 beats min (HRR ≤12) 1 min after cessation of preoperative cardiopulmonary exercise testing] was associated with perioperative myocardial injury.
We conducted a pre-defined, secondary analysis of a multi-centre prospective cohort study of preoperative cardiopulmonary exercise testing. Participants were aged ≥40 yr undergoing non-cardiac surgery. The exposure was impaired HRR (HRR≤12). The primary outcome was postoperative myocardial injury, defined by serum troponin concentration within 72 h after surgery. The analysis accounted for established markers of cardiac risk [Revised Cardiac Risk Index (RCRI), N-terminal pro-brain natriuretic peptide (NT pro-BNP)].
A total of 1326 participants were included [mean age (standard deviation), 64 (10) yr], of whom 816 (61.5%) were male. HRR≤12 occurred in 548 patients (41.3%). Myocardial injury was more frequent amongst patients with HRR≤12 [85/548 (15.5%) vs HRR>12: 83/778 (10.7%); odds ratio (OR), 1.50 (1.08-2.08); P=0.016, adjusted for RCRI). HRR declined progressively in patients with increasing numbers of RCRI factors. Patients with ≥3 RCRI factors were more likely to have HRR≤12 [26/36 (72.2%) vs 0 factors: 167/419 (39.9%); OR, 3.92 (1.84-8.34); P<0.001]. NT pro-BNP greater than a standard prognostic threshold (>300 pg ml) was more frequent in patients with HRR≤12 [96/529 (18.1%) vs HRR>12 59/745 (7.9%); OR, 2.58 (1.82-3.64); P<0.001].
Impaired HRR is associated with an increased risk of perioperative cardiac injury. These data suggest a mechanistic role for cardiac vagal dysfunction in promoting perioperative myocardial injury.
围手术期心肌损伤的病因尚不清楚，也与预先存在的心血管疾病没有明确联系。我们假设，保护性迷走神经张力的丧失[定义为术前心肺运动试验停止后 1 分钟时心率恢复<12 次/分钟（HRR<12）]与围手术期心肌损伤有关。
我们对一项多中心前瞻性队列研究的术前心肺运动试验进行了预先设定的二次分析。参与者年龄≥40 岁，行非心脏手术。暴露因素为 HRR 受损（HRR<12）。主要结局是术后心肌损伤，定义为手术后 72 小时内血清肌钙蛋白浓度升高。分析考虑了心脏风险的既定标志物[修正后的心脏风险指数（RCRI）、N 末端脑利钠肽前体（NT pro-BNP）]。
共纳入 1326 名参与者[平均年龄（标准差），64（10）岁]，其中 816 名（61.5%）为男性。548 名患者（41.3%）出现 HRR<12。HRR<12 的患者心肌损伤更为常见[85/548（15.5%）vs HRR>12：83/778（10.7%）；比值比（OR），1.50（1.08-2.08）；P=0.016，调整了 RCRI）。随着 RCRI 因素数量的增加，HRR 逐渐下降。有≥3 个 RCRI 因素的患者更有可能出现 HRR<12[26/36（72.2%）vs 0 个因素：167/419（39.9%）；OR，3.92（1.84-8.34）；P<0.001]。HRR<12 的患者 NT pro-BNP 大于标准预后阈值（>300 pg/ml）更为常见[96/529（18.1%）vs HRR>12：59/745（7.9%）；OR，2.58（1.82-3.64）；P<0.001]。
HRR 受损与围手术期心脏损伤风险增加相关。这些数据表明，心脏迷走神经功能障碍在促进围手术期心肌损伤中具有机制作用。
