使用自我报告的功能能力对非心脏手术后主要不良心血管事件进行风险评估：国际前瞻性队列研究。

Risk assessment for major adverse cardiovascular events after noncardiac surgery using self-reported functional capacity: international prospective cohort study.

机构信息

Anesthesiology Department University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany.

Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.

出版信息

Br J Anaesth. 2023 Jun;130(6):655-665. doi: 10.1016/j.bja.2023.02.030. Epub 2023 Apr 1.

DOI:10.1016/j.bja.2023.02.030

PMID:37012173

Abstract

BACKGROUND

Guidelines endorse self-reported functional capacity for preoperative cardiovascular assessment, although evidence for its predictive value is inconsistent. We hypothesised that self-reported effort tolerance improves prediction of major adverse cardiovascular events (MACEs) after noncardiac surgery.

METHODS

This is an international prospective cohort study (June 2017 to April 2020) in patients undergoing elective noncardiac surgery at elevated cardiovascular risk. Exposures were (i) questionnaire-estimated effort tolerance in metabolic equivalents (METs), (ii) number of floors climbed without resting, (iii) self-perceived cardiopulmonary fitness compared with peers, and (iv) level of regularly performed physical activity. The primary endpoint was in-hospital MACE consisting of cardiovascular mortality, non-fatal cardiac arrest, acute myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care or resulting in a prolongation of stay on ICU/intermediate care (≥24 h). Mixed-effects logistic regression models were calculated.

RESULTS

In this study, 274 (1.8%) of 15 406 patients experienced MACE. Loss of follow-up was 2%. All self-reported functional capacity measures were independently associated with MACE but did not improve discrimination (area under the curve of receiver operating characteristic [ROC AUC]) over an internal clinical risk model (ROC AUC 0.74 [0.71-0.77], ROC AUC 0.74 [0.71-0.77], ROC AUC 0.75 [0.71-0.78], AUC 0.74 [0.71-0.77], and AUC 0.75 [0.72-0.78]).

CONCLUSIONS

Assessment of self-reported functional capacity expressed in METs or using the other measures assessed here did not improve prognostic accuracy compared with clinical risk factors. Caution is needed in the use of self-reported functional capacity to guide clinical decisions resulting from risk assessment in patients undergoing noncardiac surgery.

CLINICAL TRIAL REGISTRATION

NCT03016936.

摘要

背景

指南支持自我报告的功能能力用于术前心血管评估，尽管其预测价值的证据并不一致。我们假设自我报告的耐受努力程度可以提高非心脏手术后主要不良心血管事件（MACE）的预测。

方法

这是一项国际性的前瞻性队列研究（2017 年 6 月至 2020 年 4 月），在患有高心血管风险的患者中进行择期非心脏手术。暴露因素包括：（i）通过代谢当量（METs）评估问卷的估计努力耐受程度，（ii）不休息爬的楼层数，（iii）与同龄人相比的自我感知心肺健康状况，以及（iv）定期进行的身体活动水平。主要终点是院内 MACE，包括心血管死亡率、非致命性心脏骤停、急性心肌梗死、中风和充血性心力衰竭，需要转移到更高的护理单位或导致 ICU/中间护理（≥24 小时）住院时间延长。使用混合效应逻辑回归模型进行计算。

结果

在这项研究中，15406 名患者中有 274 名（1.8%）发生 MACE。失访率为 2%。所有自我报告的功能能力测量均与 MACE 独立相关，但与内部临床风险模型相比并未提高区分度（接受者操作特征曲线下的面积 [ROC AUC]）（ROC AUC 0.74 [0.71-0.77]、ROC AUC 0.74 [0.71-0.77]、ROC AUC 0.75 [0.71-0.78]、AUC 0.74 [0.71-0.77]和 AUC 0.75 [0.72-0.78]）。