Horowitz M B, Willet D, Keffer J
Department of Neurological Surgery, UT Southwestern Medical Center at Dallas, USA.
Acta Neurochir (Wien). 1998;140(1):87-93. doi: 10.1007/s007010050063.
A prospective single center study was performed to determine the minimal preoperative incidence of unrecognized cardiac injury in patients suffering aneurysmal and presumed aneurysmal subarachnoid hemorrhage (SAH). When caring for such patients in the pre- and post operative period clinicians must be aware of the possibility of cardiac injury even when a history of previous cardiac symptomatology is not present. Forty-seven consecutive patients suffering from SAH over a five-month period underwent serum measurements of the cardiac muscle marker troponin I (cTnI) immediately upon admission. Repeat studies, if possible, were done 24 hours later. EKG was performed in all patients and was available for review in 44 of the 47 cases. Echocardiography was performed in four of eight patients with elevated cTnI levels. Signs and symptoms relating to cardiac ischemia were recorded by the patients' physicians and nurses. Eight individuals (17%) had elevations in cardiac troponin I levels. Because surgical treatment is generally carried out as soon as possible following the hemorrhage, many patients with normal troponin I levels within twenty-four hours of their hemorrhage were operated upon before a repeat enzyme could be obtained or possibly before elevations could be recorded. In addition, a number of patients were referred to our center several days post-hemorrhage at a time when marker levels may have normalized. Therefore, the 17% incidence of elevated cTnI may be an underestimate. Only two of the eight patients had clinical abnormalities in cardiac function. Four patients with elevated levels had echocardiograms, three of which were abnormal. One additional patient died of a myocardial infarction before an echocardiogram could be obtained. EKG was abnormal in six of the seven patients with elevated troponin who had tracings available for review. Recordings consistent with recent myocardial ischemia were present in four of these. Of the 39 patients with negative troponin I levels, 37 had EKG available for review. None had recordings clearly consistent with recent myocardial ischemia although 13 were suggestive of ischemic changes. None of these 39 patients had pre- or post-operative clinical changes in cardiac function. Elevations in troponin I appeared to be unrelated to the patient's Hunt and Hess grade or Fisher score although our numbers were too small to draw any meaningful conclusions.
开展了一项前瞻性单中心研究，以确定动脉瘤性蛛网膜下腔出血（SAH）及疑似动脉瘤性SAH患者术前未被识别的心脏损伤的最低发生率。在围手术期护理此类患者时，临床医生必须意识到心脏损伤的可能性，即使患者既往无心脏症状史。在五个月期间，47例连续的SAH患者入院时立即进行了心肌标志物肌钙蛋白I（cTnI）的血清检测。如有可能，24小时后进行重复检测。所有患者均进行了心电图检查，47例中有44例的心电图可供复查。8例cTnI水平升高的患者中有4例进行了超声心动图检查。患者的医生和护士记录了与心脏缺血相关的体征和症状。8例（17%）患者的心脏肌钙蛋白I水平升高。由于通常在出血后尽快进行手术治疗，许多在出血后24小时内心脏肌钙蛋白I水平正常的患者在获得重复酶检测结果之前或可能在记录到升高之前就接受了手术。此外，一些患者在出血几天后被转诊至本中心，此时标志物水平可能已恢复正常。因此，cTnI升高17%的发生率可能被低估了。8例患者中只有2例出现心脏功能临床异常。4例cTnI水平升高的患者进行了超声心动图检查，其中3例异常。另有1例患者在获得超声心动图检查结果之前死于心肌梗死。在7例cTnI升高且有心电图可供复查的患者中，6例心电图异常。其中4例有与近期心肌缺血一致的记录。在39例cTnI水平阴性的患者中，37例有心电图可供复查。尽管13例提示有缺血性改变，但均无与近期心肌缺血明确一致的记录。这39例患者中无一例在术前或术后出现心脏功能的临床变化。肌钙蛋白I升高似乎与患者的Hunt和Hess分级或Fisher评分无关，尽管我们的样本量太小，无法得出任何有意义的结论。
