University of Rochester, Rochester, New York.
McMaster University, Hamilton, Ontario, Canada.
J Bone Joint Surg Am. 2020 May 20;102(10):880-888. doi: 10.2106/JBJS.18.01305.
Myocardial injury after noncardiac surgery (MINS) is common and of prognostic importance. Little is known about MINS in orthopaedic surgery. The diagnostic criterion for MINS was a level of ≥0.03 ng/mL on a non-high-sensitivity troponin T (TnT) assay due to myocardial ischemia.
We undertook an international, prospective study of 15,103 patients ≥45 years of age who had inpatient noncardiac surgery; 3,092 underwent orthopaedic surgery. Non-high-sensitivity TnT assays were performed on postoperative days 0, 1, 2, and 3. Among orthopaedic patients, we determined (1) the prognostic relevance of the MINS diagnostic criteria, (2) the 30-day mortality rate for those with and without MINS, and (3) the probable proportion of MINS cases that would go undetected without troponin monitoring because of a lack of an ischemic symptom.
Three hundred and sixty-seven orthopaedic patients (11.9%) had MINS. MINS was associated independently with 30-day mortality including among those who had had orthopaedic surgery. Orthopaedic patients without and with MINS had a 30-day mortality rate of 1.0% and 9.8%, respectively (odds ratio [OR], 11.28; 95% confidence interval [CI], 6.72 to 18.92). The 30-day mortality rate was increased for patients with MINS who had an ischemic feature (i.e., symptoms, or evidence of ischemia on electrocardiography or imaging) (OR, 18.25; 95% CI, 10.06 to 33.10) and for those who did not have an ischemic feature (OR, 7.35; 95% CI, 3.37 to 16.01). The proportion of orthopaedic patients with MINS who were asymptomatic and in whom the myocardial injury would have probably gone undetected without TnT monitoring was 81.3% (95% CI, 76.3% to 85.4%).
One in 8 orthopaedic patients in our study had MINS, and MINS was associated with a higher mortality rate regardless of symptoms. Troponin levels should be measured after surgery in at-risk patients because most MINS cases (>80%) are asymptomatic and would go undetected without routine measurements.
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
非心脏手术后心肌损伤（MINS）很常见，具有预后意义。关于矫形外科手术中的 MINS 知之甚少。MINS 的诊断标准是由于心肌缺血，非高敏肌钙蛋白 T（TnT）检测结果≥0.03ng/mL。
我们对 15103 名年龄≥45 岁接受住院非心脏手术的患者进行了一项国际前瞻性研究；其中 3092 名患者接受了矫形外科手术。术后第 0、1、2 和 3 天进行非高敏 TnT 检测。在矫形外科患者中，我们确定了：（1）MINS 诊断标准的预后相关性；（2）有和无 MINS 的患者 30 天死亡率；（3）由于缺乏缺血症状，没有肌钙蛋白监测，MINS 病例中有多少可能未被发现。
367 名矫形外科患者（11.9%）患有 MINS。MINS 与 30 天死亡率独立相关，包括接受矫形外科手术的患者。无 MINS 和有 MINS 的矫形外科患者的 30 天死亡率分别为 1.0%和 9.8%（比值比 [OR]，11.28；95%置信区间 [CI]，6.72 至 18.92）。有 MINS 且有缺血特征（即症状或心电图或影像学上有缺血证据）的患者 30 天死亡率（OR，18.25；95%CI，10.06 至 33.10）和没有缺血特征的患者（OR，7.35；95%CI，3.37 至 16.01）均增加。在无 MINS 的患者中，无症状且心肌损伤可能未通过肌钙蛋白监测发现的患者比例为 81.3%（95%CI，76.3%至 85.4%）。
在我们的研究中，每 8 名接受矫形手术的患者中就有 1 名患有 MINS，且无论是否有症状，MINS 均与更高的死亡率相关。在高危患者中，应在手术后测量肌钙蛋白水平，因为大多数 MINS 病例（>80%）无症状，如果不进行常规测量，可能会漏诊。
预后 II 级。有关证据水平的完整描述，请参阅作者说明。
