Myocardial Injury in Critically III Patients with Community-acquired Pneumonia A Cohort Study
Myocardial Injury in Critically III Patients with Community-acquired Pneumonia A Cohort Study
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DOI：
10.1513/annalsats.201804-286oc
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发表时间：
2019-05-01
影响因子：
8.3
通讯作者：
Koster-Brouwer, Maria E.
中科院分区：
文献类型：
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作者：
Frencken, Jos F.;van Baal, Lottie;Koster-Brouwer, Maria E.
基本原理：心肌损伤，如血浆中心肌肌钙蛋白水平升高所反映的，在社区获得性肺炎（CAP）患者中很常见，但其时间动力学和病因学尚不清楚。目的：我们的目的是确定CAP患者肌钙蛋白释放的发生率，并确定可能指向潜在病因机制的危险因素。方法：我们纳入了2011年至2015年期间在荷兰两个重症监护病房连续收治的重度CAP患者。在第一周每天测量高敏心肌肌钙蛋白I。我们使用多变量线性回归，以确定入院时肌钙蛋白释放相关的变量，我们使用混合效应回归模型的肌钙蛋白水平随时间的每日上升和下降。结果：在200名符合条件的患者中，179人被纳入，产生792个观察日。共有152例（85%）患者出现肌钙蛋白水平升高，超过26 ng/L。与肌钙蛋白释放独立相关的基线因素包括冠状动脉疾病增加176%; 95%置信区间[CI]，11 - 589），吸烟（增加248%; 95% CI，33 - 809），急性生理学和慢性健康评估IV评分更高（增加2%; 95% CI，0.8 - 3.3），而金黄色葡萄球菌作为致病病原体具有保护性（减少70%; 95% CI，18 - 89）。与肌钙蛋白浓度每日增加独立相关的时间依赖性风险因素包括血小板计数减少（增加2.3%; 95% CI 0.6 - 4），心动过速（增加1.5%; 95% CI 0.1 - 2.9），低血压（增加6.2%; 95% CI，2.1 - 10.6），使用多巴酚丁胺（增加44%; 95% CI，12 - 85），凝血酶原时间（增加8.2%; 95% CI，0.2 - 16.9），白色细胞计数（增加1.7%; 95%CI，0 - 33）和发热（增加22.7%; 95%CI，0.1 - 49.6）。心肌氧供需不匹配和激活的炎症/凝血与这种损伤有关。
Rationale: Myocardial injury, as reflected by elevated cardiac troponin levels in plasma, is common in patients with community-acquired pneumonia (CAP), but its temporal dynamics and etiology remain unknown.Objectives: Our aim was to determine the incidence of troponin release in patients with CAP and identify risk factors that may point to underlying etiologic mechanisms.Methods: We included consecutive patients admitted with severe CAP to two intensive care units in the Netherlands between 2011 and 2015. High-sensitivity cardiac troponin I was measured daily during the first week. We used multivariable linear regression to identify variables associated with troponin release on admission, and we used mixed-effects regression to model the daily rise and fall of troponin levels over time.Results: Of 200 eligible patients, 179 were included, yielding 792 observation days. A total of 152 (85%) patients developed raised troponin levels greater than 26 ng/L. Baseline factors independently associated with troponin release included coronary artery disease 176% increase; 95% confidence interval [CI], 11-589), smoking (248% increase; 95% CI, 33-809), and higher Acute Physiology and Chronic Health Evaluation IV score (2% increase; 95% CI, 0.8-3.3), whereas Staphylococcus aureus as a causative pathogen was protective (70% reduction; 95% CI, 18-89). Time-dependent risk factors independently associated with daily increase in troponin concentrations included reduced platelet count (2.3% increase; 95% CI 0.6-4), tachycardia (1.5% increase; 95% CI 0.1-2.9), hypotension (6.2% increase; 95% CI, 2.1-10.6), dobutamine use (44% increase; 95% CI, 12-85), prothrombin time (8.2% increase; 95% CI, 0.2-16.9), white cell count (1.7% increase; 95% CI, 0-33), and fever (22.7% increase; 95% CI, 0.1-49.6).Conclusions: Cardiac injury develops in a majority of patients with severe CAP. Myocardial oxygen supply-demand mismatch and activated inflammation/coagulation are associated with this injury.