From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain.
Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.
Anesth Analg. 2023 Dec 1;137(6):1116-1126. doi: 10.1213/ANE.0000000000006469. Epub 2023 Apr 12.
The best use of perioperative cardiac biomarkers assessment is still under discussion. Massive postoperative troponin surveillance can result in untenably high workloads and costs for health care systems and potentially harmful interventions for patients. In a cohort of patients at risk for major adverse cardiovascular and cerebrovascular events (MACCEs), we aimed to (1) determine whether preoperative biomarkers can identify patients at major risk for acute myocardial injury in noncardiac surgery, (2) develop a risk model for acute myocardial injury prediction, and (3) propose an algorithm to optimize postoperative troponin surveillance.
Prospective, single-center cohort study enrolling consecutive adult patients (≥45 years) at risk for MACCE scheduled for intermediate-to-high-risk noncardiac surgery. Baseline high-sensitivity troponin T (hsTnT) and N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP), as well as hsTnT on the first 3 postoperative days were obtained. The main outcome was the occurrence of acute myocardial injury. Candidate predictors of acute myocardial injury were baseline concentrations of hsTnT ≥14 ng/L and NT-proBNP ≥300 pg/mL and preoperative and intraoperative variables. A multivariable risk model and a decision curve were constructed.
Of 732 patients, 42.1% had elevated hsTnT and 37.3% had elevated NT-proBNP levels at baseline. Acute myocardial injury occurred in 161 patients (22%). Elevated baseline hsTnT, found in 84% of patients with acute myocardial injury, was strongly associated with this outcome: odds ratio (OR), 12.08 (95% confidence interval [CI], 7.78-19.42). Logistic regression identified 6 other independent predictors for acute myocardial injury: age, sex, estimated glomerular filtration rate (eGFR) <45 mL·min -1 ·1.73 m -2 , functional capacity <4 METs or unknown, NT-proBNP ≥300 pg/mL, and estimated intraoperative blood loss. The c -statistic for the risk model was 77% (95% CI, 0.73-0.81). The net benefit of the model began at a risk threshold of 7%.
Baseline determination of cardiac biomarkers in patients at risk for MACCE shortly before intermediate- or high-risk noncardiac surgery helps identify those with the highest risk for acute myocardial injury. A baseline hsTnT ≥14 ng/L indicates the need for postoperative troponin surveillance. In patients with baseline hsTnT <14 ng/L, our 6-predictor model will identify additional patients at risk for acute myocardial injury who may also benefit from postoperative surveillance.
围手术期心脏生物标志物评估的最佳应用仍在讨论中。大量的术后肌钙蛋白监测可能会给医疗系统带来难以承受的高工作量和成本，并可能对患者造成潜在的有害干预。在一组有发生主要不良心血管和脑血管事件（MACCE）风险的患者中，我们旨在：（1）确定术前生物标志物是否可以识别非心脏手术中发生急性心肌损伤的高危患者，（2）建立急性心肌损伤预测风险模型，以及（3）提出优化术后肌钙蛋白监测的算法。
前瞻性、单中心队列研究纳入了有发生 MACCE 风险的连续成年患者（≥45 岁），这些患者拟接受中高危非心脏手术。采集基线高敏肌钙蛋白 T（hsTnT）和 N 末端片段 B 型利钠肽前体（NT-proBNP），以及术后第 1 至 3 天的 hsTnT。主要结局为急性心肌损伤的发生。急性心肌损伤的候选预测因子为基线 hsTnT≥14ng/L 和 NT-proBNP≥300pg/mL 以及术前和术中变量。构建多变量风险模型和决策曲线。
在 732 名患者中，42.1%的患者基线 hsTnT 升高，37.3%的患者 NT-proBNP 升高。161 名患者（22%）发生急性心肌损伤。在发生急性心肌损伤的患者中，84%的患者基线 hsTnT 升高，与该结局密切相关：比值比（OR）为 12.08（95%置信区间[CI]，7.78-19.42）。逻辑回归确定了急性心肌损伤的其他 6 个独立预测因子：年龄、性别、肾小球滤过率（eGFR）<45mL·min-1·1.73m-2、功能能力<4METs 或未知、NT-proBNP≥300pg/mL 和估计术中失血量。风险模型的 c-统计量为 77%（95%CI，0.73-0.81）。该模型的净获益始于风险阈值为 7%。
在有发生 MACCE 风险的患者接受中高危非心脏手术前不久，测定基线心脏生物标志物有助于识别发生急性心肌损伤风险最高的患者。基线 hsTnT≥14ng/L 提示需要进行术后肌钙蛋白监测。在基线 hsTnT<14ng/L 的患者中，我们的 6 个预测因子模型将识别出其他发生急性心肌损伤风险的患者，他们可能也受益于术后监测。
