围手术期心肌损伤时间依赖性表型的远期预后

BJA open Pub Date : 2025-06-01 DOI:10.1016/j.bjao.2025.100422

Mikael Fält , Rasmus Åhman , Fredrik Hammarskjöld , Sara Lyckner , Monir Jawad , Ulrika Andersson , Mats Fredrikson , Jesper Sperber , Louise Elander , Lina De Geer , Helén Didriksson , Carina Jonsson , Henrik Andersson , Michelle S. Chew

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引用次数: 0

摘要

围手术期心肌损伤（PMI）与短期主要不良心脑血管事件（MACCE）和死亡率增加相关。我们评估了基于损伤时间的PMI不同表型如何影响接受重大非心脏手术（NCS）患者的长期MACCE和死亡率。方法对1290例年龄≥50岁接受重大非心脏手术的患者进行前瞻性观察性研究。术前及术后3天测量高敏心肌肌钙蛋白T （hs-cTnT）。将患者分为四组：(1)术前hs-cTnT未升高，(2)术前单独hs-cTnT升高，(3)术前hs-cTnT正常但围手术期升高，(4)术前hs-cTnT升高但围手术期升高。主要观察指标为术后3年MACCE和死亡率。结果随访3年，1 ~ 4组患者MACCE发生率分别为17.1%、37.9%、45.2%和50.7%，病死率分别为21.4%、30.3%、30.1%和33.8%。所有PMI表型均与MACCE独立相关。术前hs-cTnT正常但围手术期升高的患者风险最高。在这种表型中，风险在第30天最大(校正优势比，4.5；95%可信区间，2.3-8.8)并持续超过3年(校正优势比，3.5；95%置信区间，2.0-5.9)。PMI与死亡率增加有关，但在多变量调整后，这种关系并不持续。结论：基于时间的hs-cTnT增加可识别预后重要的亚组。无论术前水平如何，围手术期增加与术后持续3年的MACCE高风险相关。这支持使用基于时间的PMI表型进行预后富集研究，以减轻MACCE的风险。临床试验注册编号nct03436238。

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Long-term outcomes of time-dependent phenotypes of perioperative myocardial injury☆

Background

Perioperative myocardial injury (PMI) is associated with increased short-term major adverse cardio- and cerebrovascular events (MACCE) and mortality. We evaluated how different phenotypes of PMI based on timing of injury impact long-term MACCE and mortality among patients undergoing major noncardiac surgery (NCS).

Methods

A prospective, observational study was carried out in 1290 patients aged ≥50 yr undergoing major noncardiac surgery. High-sensitivity cardiac troponin T (hs-cTnT) was measured before surgery and up to 3 days after surgery. Patients were classified into four groups: (1) no hs-cTnT elevation, (2) isolated preoperative hs-cTnT increases, (3) normal preoperative hs-cTnT with perioperative elevation, and (4) increased preoperative hs-cTnT with perioperative elevation. The main outcomes were MACCE and mortality up to 3 yr after operation.

Results

At 3-yr follow-up, MACCE had occurred in 17.1%, 37.9%, 45.2%, and 50.7% and mortality was 21.4%, 30.3%, 30.1%, and 33.8% in groups 1–4, respectively. All PMI phenotypes were independently associated with MACCE. Patients with ‘normal preoperative hs-cTnT with perioperative elevation’ appeared to have the highest risk. In this phenotype, the risk was greatest at 30 days (adjusted odds ratio, 4.5; 95% confidence interval, 2.3–8.8) and persisted over 3 yr (adjusted odds ratio, 3.5; 95% confidence interval, 2.0–5.9). PMI was associated with increased mortality, but the relationship was not sustained after multivariable adjustment.

Conclusions

Increased hs-cTnT based on timing identifies prognostically important subgroups. Perioperative increases, regardless of preoperative levels, are associated with a high risk of MACCE that is sustained up to 3 yr after surgery. This supports the use of time-based PMI phenotypes for prognostic enrichment studies to mitigate the risk of MACCE.