术后升高的心肌肌钙蛋白水平可预测非心脏手术后的全因死亡率和主要不良心血管事件：前瞻性研究的剂量反应荟萃分析。

Postoperative elevated cardiac troponin levels predict all-cause mortality and major adverse cardiovascular events following noncardiac surgery: A dose-response meta-analysis of prospective studies.

机构信息

Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China.

Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China; Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China.

出版信息

J Clin Anesth. 2023 Nov;90:111229. doi: 10.1016/j.jclinane.2023.111229. Epub 2023 Aug 11.

DOI:10.1016/j.jclinane.2023.111229

PMID:37573706

Abstract

STUDY OBJECTIVE

To perform a dose-response meta-analysis for the association between postoperative myocardial injury (PMI) in noncardiac surgery and the risk of all-cause mortality or major adverse cardiovascular event (MACE).

DESIGN

Dose-response meta-analysis of prospective studies with weighted (WL) or generalized (GL) linear and restricted cubic spline (RCS) regression.

SETTING

Teaching hospitals.

PATIENTS

Adult patients undergoing noncardiac surgery.

INTERVENTIONS

No.

MEASUREMENTS

The primary outcome was all-cause mortality. The secondary outcome was MACE.

MAIN RESULTS

29 studies (53,518 patients) were included. The overall incidence of PMI was 26.0% (95% CI 21.0% to 32.0%). Compared to those without PMI, patients with PMI had an increased risk of all-cause mortality at short- (<12 months) (cardiac troponin[cTn]I: unadj OR 1.71,95%CI 1.22 to 2.41, P < 0.001; cTnT: unadj OR 2.33,95%CI 2.07 to 2.63, P < 0.001), and long-term (≥ 12 months) (cTnI: unadj OR 1.80, 95%CI 1.63 to 1.99; cTnT: unadj OR 1.47,95%CI 1.33 to 1.62) (All P < 0.001) follow-up. For MACE, the group with elevated values was associated with an increased risk (cTnI: unadj OR 1.98, 95% CI 1.13 to 3.47, P = 0.018; cTnT: unadj OR 2.29, 95% CI 1.88 to 2.79, P < 0.001). Dose-response analysis showed positive associations between PMI (per 1× upper reference limit[URL] increment) and all-cause mortality both at short- (unadj OR) (WL, OR 1.09, 95% CI 1.09 to 1.10; GL, OR 1.06, 95% CI 1.06 to 1.07; RCS in the range of 1-2× URL, OR = 2.43, 95%CI 2.25 to 2.62) and long-term follow-up (unadj HR) (WL, OR 1.16, 95% CI 1.14 to 1.17; GL, OR 1.15, 95% CI 1.13 to 1.16; RCS in the range of 1-2.75× URL, OR = 1.23, 95%CI 1.13 to 1.33), and MACE at longest follow-up (unadj OR) (WL: OR 1.53, 95% CI 1.49 to 1.57; GL: OR 1.46, 95% CI 1.42 to 1.50; RCS in the range of 1-2 x URL, OR = 3.10, 95%CI 2.51 to 3.81) (All P < 0.001). For mild cTn increase below URL, the risk of mortality increased with every increment of 0.25xURL (WL, OR 1.03, 95% CI 1.02 to 1.03; GL, OR 1.05, 95% CI 1.03 to 1.07; RCS in the range of 0-0.5 URL, OR = 9.41, 95% CI 7.41 to 11.95) (All P < 0.001).

CONCLUSIONS

This study shows positive WL or GL and RCS dose-response relationships between PMI and all-cause mortality at short (< 12 mons)- and long-term (≥ 12 mons) follow-up, and MACE at longest follow-up. For mild cTn increase below URL, the risk of mortality also increases even with every increment of 0.25× URL.

摘要

研究目的

对非心脏手术术后心肌损伤（PMI）与全因死亡率或主要不良心血管事件（MACE）风险之间的关联进行剂量-反应荟萃分析。

设计

前瞻性研究的剂量-反应荟萃分析，采用加权（WL）或广义（GL）线性和限制性立方样条（RCS）回归。

设置

教学医院。

患者

接受非心脏手术的成年患者。

干预措施

无。

测量

主要结局是全因死亡率。次要结局是 MACE。

主要结果

纳入 29 项研究（53518 名患者）。总体 PMI 发生率为 26.0%（95%CI 21.0%至 32.0%）。与无 PMI 的患者相比，有 PMI 的患者在短期（<12 个月）（心肌肌钙蛋白 I：未调整 OR 1.71，95%CI 1.22 至 2.41，P<0.001；心肌肌钙蛋白 T：未调整 OR 2.33，95%CI 2.07 至 2.63，P<0.001）和长期（≥ 12 个月）（心肌肌钙蛋白 I：未调整 OR 1.80，95%CI 1.63 至 1.99；心肌肌钙蛋白 T：未调整 OR 1.47，95%CI 1.33 至 1.62）随访中死亡风险增加（所有 P<0.001）。对于 MACE，升高值组的风险增加（心肌肌钙蛋白 I：未调整 OR 1.98，95%CI 1.13 至 3.47，P=0.018；心肌肌钙蛋白 T：未调整 OR 2.29，95%CI 1.88 至 2.79，P<0.001）。剂量-反应分析显示，PMI（每增加 1×上参考限[URL]增量）与全因死亡率之间呈正相关，无论是短期（未调整 OR）（WL，OR 1.09，95%CI 1.09 至 1.10；GL，OR 1.06，95%CI 1.06 至 1.07；RCS 在 1-2×URL 范围内，OR=2.43，95%CI 2.25 至 2.62）还是长期随访（未调整 HR）（WL，OR 1.16，95%CI 1.14 至 1.17；GL，OR 1.15，95%CI 1.13 至 1.16；RCS 在 1-2.75×URL 范围内，OR=1.23，95%CI 1.13 至 1.33），以及最长随访时间的 MACE（未调整 OR）（WL：OR 1.53，95%CI 1.49 至 1.57；GL：OR 1.46，95%CI 1.42 至 1.50；RCS 在 1-2 x URL 范围内，OR=3.10，95%CI 2.51 至 3.81）（所有 P<0.001）。对于轻度低于 URL 的 cTn 升高，死亡率的风险随着每增加 0.25xURL 而增加（WL，OR 1.03，95%CI 1.02 至 1.03；GL，OR 1.05，95%CI 1.03 至 1.07；RCS 在 0-0.5 URL 范围内，OR=9.41，95%CI 7.41 至 11.95）（所有 P<0.001）。