心脏手术后高敏肌钙蛋白 I 与 30 天死亡率。

High-Sensitivity Troponin I after Cardiac Surgery and 30-Day Mortality.

机构信息

From McMaster University (P.J.D., A.L., M.H.M., E.P.B.-C., N.D., D.C., P.A.K., M.J.M., J.S., Y.L.M., R.M., S.F.L., S.I.B., S.H., F.K.B., G.H.G., S.Y., R.P.W.), Hamilton Health Sciences (P.J.D., A.L., E.P.B.-C., N.D., D.C., P.A.K., Y.L.M., F.K.B., G.H.G., S.Y., R.P.W.), and the Population Health Research Institute (P.J.D., A.L., M.H.M., E.P.B.-C., D.C., M.J.M., K.B., J.S., Y.L.M., R.M., S.F.L., S.I.B., F.K.B., S.P., J.V., S.Y., R.P.W.), Hamilton, Queen's University, Kingston (R.V.A., J.L.P.), and Sunnybrook Health Sciences Centre and the University of Toronto, Toronto (S.C., S.F.) - all in Ontario, Canada; the Chinese University of Hong Kong, Hong Kong (M.T.V.C., M.J.U.), and the First Affiliated Hospital of Xinjiang Medical University, Urumqi (H.Z.) - both in China; E. Meshalkin National Medical Research Center (V.V.L., M.A.) and Novosibirsk State University (V.V.L.), Novosibirsk, and the Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo (D.S.) - all in Russia; IRCCS San Raffaele Scientific Institute (G.L., E.F., F.M.) and Vita-Salute San Raffaele University (G.L., F.M.), Milan, the University of Foggia, Foggia (D.P.), and Santa Maria Hospital GVM Care and Research, Bari (D.P., V.M.) - all in Italy; the University of Malaya, Kuala Lumpur, Malaysia (C.Y.W.); Hospital de la Santa Creu i Sant Pau (G.U., M.M.) and Institut d'Investigació Biomèdica Sant Pau-CIBERESP (G.U.) - both in Barcelona; Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo (L.A.H.), and Hospital Moinhos de Vento (C.A.P.), Hospital de Clínicas de Porto Alegre (C.A.P.), and Instituto de Cardiologia do Rio Grande do Sul (R.S.), Porto Alegre - all in Brazil; Royal Perth Hospital and the University of Western Australia - both in Perth (G.S.H.); the University of Edinburgh, Edinburgh (N.L.M.), the Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool (J.D.M.), and the Royal Wolverhampton NHS Trust, Wolverhampton (J.S.B.) - all in the United Kingdom; the University of California, Los Angeles, Los Angeles (E.M.); the University of Arizona College of Medicine, Tucson (J.S.A.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (H.D.W.).

出版信息

N Engl J Med. 2022 Mar 3;386(9):827-836. doi: 10.1056/NEJMoa2000803.

DOI:10.1056/NEJMoa2000803

PMID:35235725

Abstract

BACKGROUND

Consensus recommendations regarding the threshold levels of cardiac troponin elevations for the definition of perioperative myocardial infarction and clinically important periprocedural myocardial injury in patients undergoing cardiac surgery range widely (from >10 times to ≥70 times the upper reference limit for the assay). Limited evidence is available to support these recommendations.

METHODS

We undertook an international prospective cohort study involving patients 18 years of age or older who underwent cardiac surgery. High-sensitivity cardiac troponin I measurements (upper reference limit, 26 ng per liter) were obtained 3 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We performed Cox analyses using a regression spline that explored the relationship between peak troponin measurements and 30-day mortality, adjusting for scores on the European System for Cardiac Operative Risk Evaluation II (which estimates the risk of death after cardiac surgery on the basis of 18 variables, including age and sex).

RESULTS

Of 13,862 patients included in the study, 296 (2.1%) died within 30 days after surgery. Among patients who underwent isolated coronary-artery bypass grafting or aortic-valve replacement or repair, the threshold troponin level, measured within 1 day after surgery, that was associated with an adjusted hazard ratio of more than 1.00 for death within 30 days was 5670 ng per liter (95% confidence interval [CI], 1045 to 8260), a level 218 times the upper reference limit. Among patients who underwent other cardiac surgery, the corresponding threshold troponin level was 12,981 ng per liter (95% CI, 2673 to 16,591), a level 499 times the upper reference limit.

CONCLUSIONS

The levels of high-sensitivity troponin I after cardiac surgery that were associated with an increased risk of death within 30 days were substantially higher than levels currently recommended to define clinically important periprocedural myocardial injury. (Funded by the Canadian Institutes of Health Research and others; VISION Cardiac Surgery ClinicalTrials.gov number, NCT01842568.).

摘要

背景

对于心脏手术后定义围术期心肌梗死和临床重要围术期心肌损伤的心脏肌钙蛋白升高的阈值水平，专家共识推荐范围很广（从检测方法的上限参考值的 10 倍到≥70 倍不等）。目前仅有有限的证据支持这些推荐。

方法

我们进行了一项国际前瞻性队列研究，纳入了 18 岁及以上接受心脏手术的患者。在手术后 3 至 12 小时以及手术后第 1、2 和 3 天，检测高敏心肌肌钙蛋白 I（上限参考值 26ng/升）。我们使用回归样条进行 Cox 分析，该分析探索了峰值肌钙蛋白测量值与 30 天死亡率之间的关系，调整了欧洲心脏手术风险评估系统 II 评分（根据 18 个变量，包括年龄和性别，预测心脏手术后的死亡风险）。

结果

在这项研究中，共纳入 13862 例患者，其中 296 例（2.1%）在手术后 30 天内死亡。在接受单纯冠状动脉旁路移植术或主动脉瓣置换或修复术的患者中，术后 1 天内测量的与 30 天内死亡风险比大于 1.00 相关的截断肌钙蛋白水平为 5670ng/升（95%置信区间 [CI]，1045 至 8260），为上限参考值的 218 倍。在接受其他心脏手术的患者中，相应的截断肌钙蛋白水平为 12981ng/升（95%CI，2673 至 16591），为上限参考值的 499 倍。