Perioperative Myocardial Injury After Noncardiac Surgery Incidence, Mortality, and Characterization
Perioperative Myocardial Injury After Noncardiac Surgery Incidence, Mortality, and Characterization
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DOI：
10.1161/circulationaha.117.030114
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发表时间：
2018-03-20
期刊：
影响因子：
37.8
通讯作者：
Mueller, Christian
中科院分区：
文献类型：
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作者：
Puelacher, Christian;Buse, Giovanna Lurati;Mueller, Christian
背景：围手术期心肌损伤（PMI）似乎是非心脏手术后死亡率的一个因素。由于绝大多数的PMI是无症状的，PMI通常是错过了在没有系统screening.METHODS：我们进行了一项前瞻性诊断研究，招募连续患者接受非心脏手术谁有计划的术后住院时间>= 24小时，被认为是心血管疾病的风险增加。所有患者在临床常规中使用高灵敏度心肌肌钙蛋白T的系列测量进行系统筛查。PMI定义为从术前到术后测量的绝对高灵敏度心肌肌钙蛋白T增加>= 14 ng/L。此外，死亡率进行了比较PMI不符合额外的标准（缺血症状，新的心电图变化，或存活心肌的损失的影像学证据）所需的诊断自发性急性心肌梗死与那些做了.RESULTS：从2014年至2015年，我们纳入了2018例连续患者接受2546次手术。患者的中位年龄为74岁，42%为女性。2546例手术中有397例（16%; 95%置信区间，14%-17%）发生PMI，397例患者中有24例（6%）伴有典型胸痛，397例患者中有72例（18%）伴有任何缺血性症状。PMI患者的30天粗死亡率为8.9%（95%置信区间[CI]，5.7-12.0），而非PMI患者的30天粗死亡率为1.5%（95% CI，0.9-2.0）（P< 0.001）。多变量回归分析显示30天死亡率的校正风险比为2.7（95% CI，1.5-4.8）。差异在1年时保持，死亡率为22.5%（95% CI，17.6-27.4）vs 9.3%（95% CI，7.9-10.7）。30天死亡率与PMI不符合任何其他自发性急性心肌梗死所需标准的患者相似（280/397，71%）与至少有1项其他标准的患者相比（10.4%; 95%CI，6.7-15.7，对8.7%; 95%CI，4.2-16.7; P= 0.684）.结论：PMI是非心脏手术后的常见并发症，尽管在常规临床筛查中早期发现，但与大量的短期和长期死亡率相关。不符合任何其他自发性急性心肌梗死所需标准的PMI患者的死亡率似乎与符合这些标准的患者相当。
BACKGROUND: Perioperative myocardial injury (PMI) seems to be a contributor to mortality after noncardiac surgery. Because the vast majority of PMIs are asymptomatic, PMI usually is missed in the absence of systematic screening.METHODS: We performed a prospective diagnostic study enrolling consecutive patients undergoing noncardiac surgery who had a planned postoperative stay of >= 24 hours and were considered at increased cardiovascular risk. All patients received a systematic screening using serial measurements of high-sensitivity cardiac troponin T in clinical routine. PMI was defined as an absolute high-sensitivity cardiac troponin T increase of >= 14 ng/L from preoperative to postoperative measurements. Furthermore, mortality was compared among patients with PMI not fulfilling additional criteria (ischemic symptoms, new ECG changes, or imaging evidence of loss of viable myocardium) required for the diagnosis of spontaneous acute myocardial infarction versus those that did.RESULTS: From 2014 to 2015 we included 2018 consecutive patients undergoing 2546 surgeries. Patients had a median age of 74 years and 42% were women. PMI occurred after 397 of 2546 surgeries (16%; 95% confidence interval, 14%-17%) and was accompanied by typical chest pain in 24 of 397 patients (6%) and any ischemic symptoms in 72 of 397 (18%). Crude 30-day mortality was 8.9% (95% confidence interval [CI], 5.7-12.0) in patients with PMI versus 1.5% (95% CI, 0.9-2.0) in patients without PMI (P< 0.001). Multivariable regression analysis showed an adjusted hazard ratio of 2.7 (95% CI, 1.5-4.8) for 30-day mortality. The difference was retained at 1 year with mortality rates of 22.5% (95% CI, 17.6-27.4) versus 9.3% (95% CI, 7.9-10.7). Thirty-day mortality was comparable among patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction (280/397, 71%) versus those with at least 1 additional criterion (10.4%; 95% CI, 6.7-15.7, versus 8.7%; 95% CI, 4.2-16.7; P= 0.684).CONCLUSIONS: PMI is a common complication after noncardiac surgery and, despite early detection during routine clinical screening, is associated with substantial short-and long-term mortality. Mortality seems comparable in patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction versus those patients who do.