Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa.
S Afr Med J. 2021 Mar 31;111(4):338-342. doi: 10.7196/SAMJ.2021.v111i4.15226.
International guidelines recommend risk stratification to identify high-risk non-cardiac surgical patients. It is also recommended that all patients aged ≥45 years with significant cardiovascular disease should have preoperative natriuretic peptide (NP) testing. Abnormal preoperative B-type NPs have a strong association with postoperative cardiac complications. In South African hospitals, it is not known how many patients with significant cardiovascular disease scheduled for intermediate- to high-risk surgery will have raised NPs.
To determine the prevalence of abnormal (raised) NPs in non-cardiac surgical patients with cardiac clinical risk factors. A secondary objective was to develop a model to identify surgical patients who may benefit from preoperative NP screening.
The inclusion criteria were patients aged ≥45 years presenting for elective, non-obstetric, intermediate- to high-risk non-cardiac surgery with at least one of the following cardiovascular risk factors: a history of ischaemic heart disease or peripheral vascular disease (coronary equivalent); a history of stroke or transient ischaemic attack; a history of congestive cardiac failure; diabetes mellitus currently on an oral hypoglycaemic agent or insulin; and serum creatinine level >175 µmol/L (>2.0 mg/dL). Blood samples for N-terminal-prohormone B-type NP (NT-proBNP) were collected before induction of anaesthesia. The preoperative prognostic threshold for abnormal (raised) NT-proBNP was ≥300 pg/mL. A generalised linear mixed model was used to determine the association between the risk factors and an abnormal NT-proBNP level.
Of 172 patients, 63 (37%) had an elevated preoperative NT-proBNP level. The comorbidities independently associated with elevated preoperative NT-proBNP were coronary artery disease or peripheral vascular disease, congestive cardiac failure, and a creatinine level >175 µmol/L
We strongly recommend that non-cardiac surgical patients aged ≥45 years undergoing intermediate- or high-risk noncardiac surgery with a history of coronary artery disease/peripheral vascular disease, congestive cardiac failure or elevated creatinine have preoperative NP testing as part of risk stratification.
国际指南建议进行风险分层，以识别高危非心脏手术患者。还建议所有年龄≥45 岁且有明显心血管疾病的患者均应进行术前利钠肽（NP）检测。术前异常 B 型 NP 与术后心脏并发症有很强的关联。在南非医院，尚不清楚有多少计划接受中高危手术的有明显心血管疾病的患者 NP 升高。
确定有心脏临床危险因素的非心脏手术患者中异常（升高）NP 的患病率。次要目标是建立一个模型，以确定可能受益于术前 NP 筛查的手术患者。
纳入标准为年龄≥45 岁、因至少有以下心血管危险因素之一而择期接受中高危非心脏手术的非产科患者：缺血性心脏病或外周血管疾病（冠心病等效）病史；中风或短暂性脑缺血发作史；充血性心力衰竭史；目前正在服用口服降糖药或胰岛素的糖尿病；血清肌酐水平>175μmol/L（>2.0mg/dL）。在麻醉诱导前采集 N 末端前体 B 型利钠肽（NT-proBNP）血样。术前异常（升高）NT-proBNP 的预测阈值为≥300pg/mL。使用广义线性混合模型确定危险因素与异常 NT-proBNP 水平之间的关联。
在 172 例患者中，有 63 例（37%）术前 NT-proBNP 水平升高。与术前 NT-proBNP 升高独立相关的合并症是冠状动脉疾病或外周血管疾病、充血性心力衰竭和肌酐水平>175μmol/L。
我们强烈建议年龄≥45 岁、有冠状动脉疾病/外周血管疾病、充血性心力衰竭或肌酐升高史的中高危非心脏手术患者在进行非心脏手术时，将术前 NP 检测作为风险分层的一部分。
