High-Sensitivity Troponin I after Cardiac Surgery and 30-Day Mortality
High-Sensitivity Troponin I after Cardiac Surgery and 30-Day Mortality
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DOI：
10.1056/nejmoa2000803
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发表时间：
2022-03-03
影响因子：
158.5
通讯作者：
Whitlock, Richard P.
中科院分区：
文献类型：
--
作者：
Devereaux, P. J.;Lamy, Andre;Whitlock, Richard P.
背景关于心脏手术患者围手术期心肌梗死和临床上重要的围手术期心肌损伤定义的心肌肌钙蛋白升高阈值水平的共识建议范围很广（从检测参考上限的>10倍到>=70倍）。支持这些建议的证据有限。方法我们开展了一项国际前瞻性队列研究，对象为 18 岁或以上接受心脏手术的患者。术后 3 至 12 小时以及术后第 1、2 和 3 天获得高灵敏度心肌肌钙蛋白 I 测量（参考上限，26 ng/L）。我们使用回归样条进行 Cox 分析，探讨峰值肌钙蛋白测量值与 30 天死亡率之间的关系，并调整欧洲心脏手术风险评估 II 系统的分数（该系统根据年龄和性别等 18 个变量估计心脏手术后的死亡风险）。 结果 在研究中纳入的 13,862 名患者中，296 名 (2.1%) 患者在术后 30 天内死亡。在接受离体冠状动脉旁路移植术或主动脉瓣置换或修复术的患者中，术后 1 天内测量的肌钙蛋白阈值水平（与 30 天内死亡的调整后风险比超过 1.00 相关）为 5670 ng/L（95% 置信区间 [CI]，1045 至 8260），该水平是参考上限的 218 倍。在接受其他心脏手术的患者中，相应的阈值肌钙蛋白水平为 12,981 ng/L（95% CI，2673 至 16,591），是参考上限的 499 倍。 结论 心脏手术后与 30 天内死亡风险增加相关的高敏肌钙蛋白 I 水平显着高于目前推荐的定义临床重要围手术期心肌损伤的水平。 （由加拿大健康研究所和其他机构资助；VISION 心脏手术 ClinicalTrials.gov 编号，NCT01842568。）
BACKGROUNDConsensus recommendations regarding the threshold levels of cardiac troponin elevations for the definition of perioperative myocardial infarction and clinically important periprocedural myocardial injury in patients undergoing cardiac surgery range widely (from >10 times to >= 70 times the upper reference limit for the assay). Limited evidence is available to support these recommendations.METHODSWe undertook an international prospective cohort study involving patients 18 years of age or older who underwent cardiac surgery. High-sensitivity cardiac troponin I measurements (upper reference limit, 26 ng per liter) were obtained 3 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We performed Cox analyses using a regression spline that explored the relationship between peak troponin measurements and 30-day mortality, adjusting for scores on the European System for Cardiac Operative Risk Evaluation II (which estimates the risk of death after cardiac surgery on the basis of 18 variables, including age and sex).RESULTSOf 13,862 patients included in the study, 296 (2.1%) died within 30 days after surgery. Among patients who underwent isolated coronary-artery bypass grafting or aortic-valve replacement or repair, the threshold troponin level, measured within 1 day after surgery, that was associated with an adjusted hazard ratio of more than 1.00 for death within 30 days was 5670 ng per liter (95% confidence interval [CI], 1045 to 8260), a level 218 times the upper reference limit. Among patients who underwent other cardiac surgery, the corresponding threshold troponin level was 12,981 ng per liter (95% CI, 2673 to 16,591), a level 499 times the upper reference limit.CONCLUSIONSThe levels of high-sensitivity troponin I after cardiac surgery that were associated with an increased risk of death within 30 days were substantially higher than levels currently recommended to define clinically important periprocedural myocardial injury. (Funded by the Canadian Institutes of Health Research and others; VISION Cardiac Surgery ClinicalTrials.gov number, NCT01842568.)