Circulation：非心脏手术后的心肌损伤增加短期死亡率

为进一步鉴别手术后心肌损伤和死亡风险，专家常建议非心脏手术后常规检查肌钙蛋白。来自荷兰的研究人员Judith A.R. van Waes等所在的医院也进行了术后的肌钙蛋白检测。他们通过本研究旨在确定非心脏手术后的心肌损伤（肌钙蛋白升高）是否对术后30天死亡率有预测价值。该研究结果发表在6月11日的Circulation杂志上。

该研究为单中心观察性队列研究，共纳入2011年间2232例连续、中到高危、年龄≥60岁的非心脏外科手术患者。在术后前3天测定肌钙蛋白。采用log-binomial回归模型评估手心肌损伤（肌钙蛋白 I >0.06 μg/L）与30天内全因死亡率的关系。在有肌钙蛋白I检查的1627例患者中，315例患者存在心肌损伤（19%）。全因死亡率为3%（56例）。肌钙蛋白略升高（0.07–0.59 μg/L）的相对危险度为2.4（95% CI, 1.3–4.2; P<0.01），而对于肌钙蛋白升高10-100倍的患者组（≥0.60 μg/L）的相对危险度为4.2（95% CI, 2.1–8.6; P<0.01）。按照心肌梗死的统一定义有10例患者确诊心肌梗死（6%），其中有1例有ST段抬高型心肌梗死。

研究人员在文中最后指出，非心脏手术的心肌损伤是患者术后30天死亡率的一独立预测因素。手术后进行肌钙蛋白检查作为一项标准监护切实可行，且有助于改善非心脏手术患者预后。

Myocardial injury after noncardiac surgery and its association with short-term mortality.
BACKGROUND
To identify patients at risk for postoperative myocardial injury and death, measuring cardiac troponin routinely after noncardiac surgery has been suggested. Such monitoring was implemented in our hospital. The aim of this study was to determine the predictive value of postoperative myocardial injury, as measured by troponin elevation, on 30-day mortality after noncardiac surgery.
METHODS AND RESULTS
This observational, single-center cohort study included 2232 consecutive intermediate- to high-risk noncardiac surgery patients aged ≥60 years who underwent surgery in 2011. Troponin was measured on the first 3 postoperative days. Log binomial regression analysis was used to estimate the association between postoperative myocardial injury (troponin I level >0.06 μg/L) and all-cause 30-day mortality. Myocardial injury was found in 315 of 1627 patients in whom troponin I was measured (19%). All-cause death occurred in 56 patients (3%). The relative risk of a minor increase in troponin (0.07-0.59 μg/L) was 2.4 (95% confidence interval, 1.3-4.2; P<0.01), and the relative risk of a 10- to 100-fold increase in troponin (≥0.60 μg/L) was 4.2 (95% confidence interval, 2.1-8.6; P<0.01). A myocardial infarction according to the universal definition was diagnosed in 10 patients (0.6%), of whom 1 (0.06%) had ST-segment elevation myocardial infarction.
CONCLUSIONS
Postoperative myocardial injury is an independent predictor of 30-day mortality after noncardiac surgery. Implementation of postoperative troponin monitoring as standard of care is feasible and may be helpful in improving the prognosis of patients undergoing noncardiac surgery.