围术期测量肌钙蛋白识别非心脏大手术心肌损伤以及修订心脏危险指数的效果

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围术期测量肌钙蛋白识别非心脏大手术心肌损伤以及修订心脏危险指数的效果

贵州医科大学 麻醉与心脏电生理课题组

翻译：胡廷菊 编辑：潘志军 审校：曹莹

背景 围术期心肌损伤的病人存在死亡和主要心脑血管不良事件（MACCE）的风险。这项研究的主要目的是确定术前和围术期高敏肌钙蛋白（hs-cTnT）变化的最佳阈值，以预测MACCE和死亡率。 

方法 这是一项前瞻性，观察性，队列研究，纳入瑞士7家医院择期行非心脏大手术，年龄≥50岁的病人。分别于术前及术后0-3天测量hs-cTnT。用多变量logistic回归模型评估两项先前发表的心肌损伤阈值和两项通过受试者操作特征分析确定的阈值并进行外部验证。当比较修订心脏风险指数（RCRI）时，采用加权比较获益法确定hs-cTnT阈值的附加值。主要结局是30天全因死亡率及MACCE的综合结果。 

结果 这项研究纳入了2017年4月到2020年12月的1291个病人。124（9.6%）例病人发生了主要结局事件。围手术期hs-cTnT基于术前增加 ≥14 ng/ L ，提供了统计学上最优的模型性能，且与主要结局的最高风险有关（调整风险比为2.9，95%CI 1.8-4.7）。一项独立的外部队列验证证实了这些发现。一系列临床阈值范围证实了RCRI获益。    

结论 围手术期hs-cTnT较术前增加 ≥14 ng/ L 可识别围术期急性心肌损伤，且结合RCRI可预测死亡及高风险MACCE的发生。

原始文献来源 ???? Michelle S Chew , Christian Puelacher , Akshaykumar Patel.et al.Identifification of myocardial injury using perioperative troponin surveillance in major noncardiac surgery and net benefifit over the Revised Cardiac Risk Index.Br J Anaesth. 2022 Jan;128(1):26-36. doi: 10.1016

英文原文 CIdentification of myocardial injury using perioperative troponin surveillance in major noncardiac surgery and net benefifit over the Revised Cardiac Risk Index Abstract Background: : Patients with perioperative myocardial injury are at risk of death and major adverse cardiovascular and cerebrovascular events (MACCE). The primary aim of this study was to determine optimal thresholds of preoperative and perioperative changes in high-sensitivity cardiac troponin T (hs-cTnT) to predict MACCE and mortality. 

Methods:Prospective, observational, cohort study in patients≥50 yr of age undergoing elective major noncardiac surgery at seven hospitals in Sweden. The exposures were hs-cTnT measured before and days 0-3 after surgery. Two previously published thresholds for myocardial injury and two thresholds identified using receiver operating characteristic analyses were evaluated using multivariable logistic regression models and externally validated. The weighted comparison net benefit method was applied to determine the additional value of hs-cTnT thresholds when compared with the Revised Cardiac Risk Index (RCRI). The primary outcome was a composite of 30-day all-cause mortality and MACCE. 

Results: We included 1291 patients between April 2017 and December 2020. The primary outcome occurred in 124 patients (9.6%). Perioperative increase in hs-cTnT ≥14 ng/ L above preoperative values provided statistically optimal model performance and was associated with the highest risk for the primary outcome (adjusted odds ratio 2.9, 95% confidence interval 1.8-4.7). Validation in an independent, external cohort confirmed these findings. A net benefit over RCRI was demonstrated across a range of clinical thresholds. 

Conclusion:Perioperative increases in hsTnT ≥14 ng/ L above baseline values identifies acute perioperative myocardial injury and provides a net prognostic benefit when added to RCRI for the identification of patients at high risk of death and MACCE.

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