From the Unité Mixte de Recherche 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France.
Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique - Bioinformatique, Lyon, France.
Anesth Analg. 2021 Oct 1;133(4):915-923. doi: 10.1213/ANE.0000000000005528.
For more than 20 years, hip fracture 1-year mortality has remained around 20%. An elevation of the postoperative troponin peak within 72 hours (myocardial injury after noncardiac surgery [MINS]) is associated with a greater risk of short-term mortality in the general population. However, there seem to be conflicting results in the specific population who undergo hip fracture surgery, with some studies finding an association between troponin and mortality and some not. The objective of the present study was to investigate the association of MINS and the short- (before 28th day), intermediate- (before 180th day), and long-term (before 365th day) mortality after hip fracture surgery.
We conducted a single-center retrospective cohort of patients undergoing hip fracture surgery from November 2013 to December 2015. MINS was defined as postoperative troponin peak within the 72 hours >5 ng/L. Four MINS subgroups were defined according to the value of troponin peak (ie, ≥5-<20, ≥20-<65, ≥65-<1000, and ≥1000 ng/L). To document the association between the different mortality terms and the troponin peak, odds ratio (OR) and adjusted OR (aOR) associated with their 95% confidence interval (CI) with the log of the scaled troponin peak within 72 hours were estimated, with and without patients presenting a postoperative acute coronary syndrome (ACS). Cox proportional hazards modeling was used to estimate hazard ratio (HR) and adjusted HR (aHR) of death between the no MINS and MINS subgroups. The adjustment was performed on the main confounding factors (ie, sex, American Society of Anesthesiologists [ASA] physical status, dementia status, age, and time from admission to surgery).
Among 729 participants, the mean age was 83.1 (standard deviation [SD] = 10.8) years, and 77.4% were women; 30 patients presented an ACS (4%). Short-, intermediate-, and long-term mortality were at 5%, 16%, and 23%, respectively. The troponin peak was significantly associated with all terms of mortality before and after adjustment and before and after exclusion of patients presenting an ACS. HR and aHR for each subgroup of troponin level were significantly associated with an increased probability of survival, except for the 5 to 20 ng/L group for which aHR was not significant (1.75, 95% CI, 0.82-3.74). In the landmark analysis, there was still an association between survival at the 365th day and troponin peak after the short- and intermediate-term truncated mortality.
MINS is associated with short-, intermediate-, and long-term mortality after hip fracture surgery. This could be a valuable indicator to determine the population at high risk of mortality that could benefit from targeted prevention and possible intervention.
20 多年来，髋部骨折患者术后 1 年的死亡率一直保持在 20%左右。术后 72 小时内肌钙蛋白峰值升高（非心脏手术后心肌损伤[MINS]）与普通人群短期死亡率升高相关。然而，在接受髋部骨折手术的特定人群中，似乎存在相互矛盾的结果，一些研究发现肌钙蛋白与死亡率之间存在关联，而另一些研究则没有。本研究旨在探讨 MINS 与髋部骨折手术后短期（28 天前）、中期（180 天前）和长期（365 天前）死亡率的关系。
我们进行了一项单中心回顾性队列研究，纳入了 2013 年 11 月至 2015 年 12 月期间接受髋部骨折手术的患者。MINS 定义为术后 72 小时内肌钙蛋白峰值>5ng/L。根据肌钙蛋白峰值的不同值（即≥5-<20、≥20-<65、≥65-<1000 和≥1000ng/L），将 MINS 分为四个亚组。为了记录不同死亡率与肌钙蛋白峰值之间的关系，我们使用 72 小时内肌钙蛋白峰值的对数估计了与肌钙蛋白峰值相关的比值比（OR）和调整比值比（aOR）及其 95%置信区间（CI），并分别记录了有和没有术后急性冠状动脉综合征（ACS）患者的情况。Cox 比例风险模型用于估计无 MINS 和 MINS 亚组之间的死亡风险比（HR）和调整风险比（aHR）。调整因素为主要混杂因素（即性别、美国麻醉医师协会[ASA]身体状况、痴呆状态、年龄和入院至手术时间）。
在 729 名参与者中，平均年龄为 83.1（标准差[SD] = 10.8）岁，77.4%为女性；30 名患者出现 ACS（4%）。短期、中期和长期死亡率分别为 5%、16%和 23%。肌钙蛋白峰值与死亡率的所有指标均显著相关，且无论是否校正以及是否排除出现 ACS 的患者均如此。每个肌钙蛋白水平亚组的 HR 和 aHR 与生存率的提高显著相关，除了 5 至 20ng/L 组的 aHR 不显著（1.75，95%CI，0.82-3.74）。在里程碑分析中，在截断短期和中期死亡率后，365 天时的生存仍然与肌钙蛋白峰值相关。
MINS 与髋部骨折手术后的短期、中期和长期死亡率相关。这可能是一个有价值的指标，可以确定处于高死亡率风险的人群，以便进行有针对性的预防和可能的干预。
