Short- and long-term prognostic value of postoperative cardiac troponin I concentration in patients undergoing coronary artery bypass grafting

BACKGROUND: The value of postoperative cardiac troponin I (cTnI) has been shown to indicate a higher risk of in-hospital death after cardiac surgery. The authors therefore assessed the long-term prognostic value of cTnI in patients undergoing elective coronary artery bypass grafting. METHODS: Consecutive patients (n = 202) were included and divided into two groups according to the postoperative value of cTnI (< or >/= 13 ng/ml). In-hospital mortality and nonfatal cardiac events (delayed extubation > 24 h; postoperative requirement of inotropic agent; ventricular and supraventricular arrhythmia; postoperative myocardial infarction) were recorded. Survivors were then followed up over a 2-yr period. Data are median and odds ratio (95% confidence interval). RESULTS: Of all patients, 174 (86%) had a low cTnI (4.1 ng/ml; range, 1.1-12.6) and 28 (14%) had a high cTnI (23.8 ng/ml; range, 13.4-174.6). In-hospital mortality was not significantly different (4 vs. 2%), whereas long-term mortality (18 vs. 3%, P = 0.006) and mortality from cardiac cause (18 vs. 1%, P < 0.001) was greater in patients with a high cTnI. A high cTnI was a significant factor predicting death (odds ratio, 7.3 [2.0-27.1]) or death from cardiac causes (odds ratio, 37.4 [4.2-334.4]). Nonfatal cardiac events were also more frequent in the hospital (64 vs. 41%, P = 0.02) and within the 2-yr follow-up period (39% vs. 16%, P = 0.03) in patients with high cTnI. CONCLUSION: A high postoperative peak of cTnI is associated with increased risk of death, death from cardiac causes, and nonfatal cardiac events within 2 yr after coronary artery bypass grafting.     

右美托咪定预处理对心脏瓣膜置换术患者心肌肌钙蛋白Ⅰ和心肌酶学的影响

【摘要】〓目的〓观察右美托咪定预处理对脏瓣膜置换术患者心肌肌钙蛋白Ⅰ和心肌酶学的影响,探讨其对缺血再灌注损伤心肌的保护作用。方法〓拟择期行瓣膜置换术患者50例随机分为右美托咪定组(D组,n=25)和对照组(C组,n=25)。D组在麻醉诱导前经15 min静脉泵注右美托咪定0.5 μg/kg,随后以0.5 μg·kg^-1·h^-1速率泵注至阻断主动脉。C组泵注等容量生理盐水。所有患者手术前(T₀),主动脉阻断30 min(T₁)、主动脉开放1 h(T₂),术毕(T₃)和术后24小时(T₄)抽血测定磷酸肌酸激酶(CK)、磷酸肌酸激酶同工酶(CK-MB)的活性及心肌肌钙蛋白I(cTnI)的浓度。观察自动复跳率、心律失常发生率、左室射血分数(LVEF)以及血管活性药物使用情况。结果〓与C组相比,D组的cTnI浓度、CK和CK-MB的活性、多巴胺和肾上腺素用量低于C组;两组自动复跳率和心律失常发生率无统计学差异;D组术后LVEF值高于C组。结论〓右美托咪定预处理可减轻瓣膜置换患者的心肌损伤。     

Predictors of cardiac events in high-risk patients undergoing emergency surgery

Background: The aim of this study was to determine the incidence of myocardial damage and left ventricular myocardial dysfunction and their influence on outcome in high-risk patients undergoing non-elective surgery.
Methods: In this prospective observational study, 211 patients with American Society of Anesthesiologists classification III or IV undergoing emergent or urgent surgery were included.
Troponin I (TnI) was measured pre-operatively, 12 and 48 h post-operatively. Pre-operative N-terminal fragment of B-type natriuretic peptide (NT-proBNP), as a marker for left ventricular systolic dysfunction, was analyzed. The diagnostic thresholds were set to TnI >0.06 μg/l and NT-proBNP >1800 pg/ml, respectively. Post-operative major adverse cardiac events (MACE), 30-day and 3-months mortality were recorded.
Results: Elevated TnI levels were detected in 33% of the patients post-operatively. A TnI elevation increased the risk of MACE (35% vs. 3% in patients with normal TnI levels, P <0.001) and 30-day mortality (23% vs. 7%, P =0.003). Increased concentrations of NT-proBNP were seen in 59% of the patients. Elevated NT-proBNP was an independent predictor of myocardial damage post-operatively, odds ratio, 6.2 [95% confidence interval (CI) 2.1–18.0] and resulted in an increased risk of MACE (21% vs. 2.5% in patients with NT-proBNP ≤1800 pg/ml, P <0.001).
Conclusion: Myocardial damage is common in a high-risk population undergoing unscheduled surgery. These results suggest a close correlation between myocardial damage in the post-operative period and increased concentration of NT-proBNP before surgery. The combinations of TnI and NT-proBNP are reliable markers for monitoring patients at risk in the peri-operative period as well as useful tools in our risk assessment pre-operatively in emergency surgery.     

Predictive value of high-sensitive cardiac troponin T (cTnT) for adverse cardiac events in patients undergoing primary total knee arthroplasty (TKA)

BackgroundElevated high-sensitive cardiac troponin T (cTnT) is a well-known biomarker to predict cardiac events following non-cardiac surgery. However, further information regarding high-sensitive cTnT in orthopedic surgery, especially total knee arthroplasty (TKA), is not present yet. This study aims to gain further insight into the predictive value of high-sensitive cTnT in adverse cardiac events in patients accepting TKA.MethodsWe performed a prospective study in our hospital with the aim to enrolling 789 consecutive patients. Included patients who underwent TKA had mean ages of 65 years, and 64.9% were female. High-sensitive cTnT measurements were performed for study purposes before operation and on 1st postoperative days respectively. Postoperative cardiac events (POCE) 2 months and 2 years postoperatively were used to be evaluated for present study and defined short-term and long-term POCE respectively. The cut-off value of high-sensitive cTnT predicting patients at increased risks of POCE was evaluated by the Receiver Operating Characteristic (ROC) curve analysis.ResultsMean preoperative, postoperative cTnT and difference value between preoperative and postoperative cTnT (D-cTnT) were 20, 32, 12 ng/L respectively. 2-month and 2-year cardiac event rate following TKA were 2.3% and 3.4%. Using difference value between preoperative and postoperative cTnT (D-cTnT) to predict short-term cardiac events, the best cut-off was 23 ng litre-1, with an AUC of 0.84 (95% CI: 0.79–0.89, p < 0.001), which was better in comparison to preoperative and postoperative cTnT. In contrast, using preoperative cTnT to predict long-term cardiac events, the best cut-off was 25 ng litre-1 with an AUC of 0.78 (95% CI: 0.73–0.83, p < 0.001), which was better in comparison to postoperative and D-cTnT.ConclusionsD-cTnT best predicted short-term POCE in comparison to preoperative and postoperative cTnT, while preoperative cTnT level best predicted long-term POCE in comparison to postoperative cTnT and D-cTnT.     

米力农对心肺转流心瓣膜置换术患者心肌缺血-再灌注损伤的影响

目的比较心肺转流(CPB)下心瓣膜置换术使用米力农和硝酸甘油时患者血浆中心肌肌钙蛋白I(cTnI)及肌酸激酶同功酶MB(CK-MB)水平的变化,了解其对心肌缺血-再灌注损伤的影响.方法择期心内直视手术心瓣膜置换患者24例,分为米力农组(M组)和硝酸甘油组(N组),每组12例.分别于全麻诱导前(T0)、主动脉开放后10min(T1)和术毕(T2)抽取患者中心静脉血,测定cTnI和CK-MB血浆水平.结果M组cTnI在T1和T2均较N组低(P＜0.05).两组CK-MB组间比较M组略低于N组(P＞0.05).M组和N组内cTnI、CK-MB在T1和T2所测定值均高于T0(P＜0.05),且T2高于T1(P＜0.05).两组cTnI、CK-MB随时间推移呈明显上升趋势.结论CPB下行心瓣膜置换术时使用米力农比使用硝酸甘油更有可能改善心肌的缺血-再灌注损伤.     

骨折患者的院内急诊护理体会

目的：探讨骨折患者在急诊期间的护理要点；方法：回顾性总结近5年来有护理记录骨折病人相关资料；结果：无1例因护理不当致医源性病情加重和医疗事故纠纷；结论：急诊时通过快速的创伤评估和诊断检查、娴熟的护理操作、骨折简单外固定和止血包扎、正确的搬运与详细的交接，可使骨折患者平稳、安全地渡过入院前期。     

Risk stratification with cardiac troponin I in patients undergoing elective coronary artery bypass surgery.

OBJECTIVE: Cardiac troponin I (cTnI) is a highly sensitive and specific marker for postoperative prediction of patients outcome after coronary artery bypass surgery (CABG). Whether preoperatively elevated cTnI levels similarly predict the outcome in patients scheduled for elective CABG is currently unknown. METHODS: Therefore, a possible correlation between preoperative cTnI levels and perioperative major adverse events and in-hospital mortality after CABG was investigated. CTnI was measured within 24h before surgery in 1405 out of 3124 consecutive elective CABG patients. Out of these patients, 1178 had a preoperative cTnI level below 0.1ng/ml (group 1), 163 patients had a cTnI level between 0.11 and 1.5ng/ml (group 2), and 64 patients had a cTnI level above 1.5ng/ml (group 3). CTnI levels, electrocardiograms, clinical data, adverse events and in-hospital mortality were recorded prospectively. Patients with ST-elevation myocardial infarction less than 7 days before surgery were excluded from the study. RESULTS: Perioperative myocardial infarction (PMI) occurred in 69/1178 patients (5.9%) in group 1, 14/163 patients (8.6%; odds ratio (OR) 1.5, 95% confidence interval (CI): 0.8-2.8) in group 2, and 11/64 patients (17.2%; OR 3.3, CI: 1.6-7.0) in group 3 (overall: P<0.001, Cochran-Armitage trend test). Low cardiac output syndrome (LCOS) occurred in 19/1178 patients (1.6%), 9/163 (5.5%; OR 3.6, CI: 1.5-8.5), and 7/64 patients (10.9%; OR 7.5, CI: 2.7-19.8) (overall: P<0.001, group 1 vs. group 2: P<0.002), respectively. In-hospital mortality was 1.7% in group 1 and 3.1% in group 2, but 6.3% (OR 3.9, CI: 1.1-12.5) in group 3 (overall: P<0.01, group 1 vs. group 2: P=NS). Intensive care and hospital stay were significantly longer in group 3 compared to groups 1 and 2. Univariate and multivariate logistic regression analysis confirmed the statistically significant relationship between cTnI and PMI, LCOS and in-hospital mortality, respectively (P<0.001). CONCLUSIONS: Risk stratification by measurement of cTnI levels within 24h before elective CABG clearly identifies a subgroup of patients with increased risk for postoperative adverse outcome and in-hospital mortality.     

Assessed value of high-sensitivity cardiac troponin T for cardiovascular disease among CKD patients

Objective To analyze the relationship between serum high-sensitivity cardiac troponin T (hs-cTnT) and cardiovascular disease (CVD) among non-dialysis chronic kidney disease (CKD) patients, and to further explore its value of evaluating and predicting CVD in this population. Methods Five hundred and fifty-seven non-dialysis CKD patients were involved in this cross-sectional study. The relationship between serum hs-cTnT and CVD was analyzed using comparison between groups and regression analysis, and its value on assessing cardiac structure and function was evaluated by ROC curves. Results Median level of hs-cTnT was 13 (7–29) ng/L, with 1.7% undetectable, 46.4% greater than 99th percentile of the general population. Multivariate analysis suggested that compared with the lowest quartile of hs-cTnT, the highest quartile was approximately six times as likely to develop into LVH (OR, 6.515; 95% CI, 3.478–12.206, p?<?0.05) and 18 times as likely to progress to left ventricular diastolic dysfunction(OR, 18.741; 95% CI, 2.422–145.017, p?<?0.05). And Ln cTnT level had a more modest association with LVEF (OR, ?1.117; 95% CI, ?5.839 to ?0.594; p?<?0.05). When evaluated as a screening test, the area under the curve of ROC curves for hs-cTnT was 0.718, 0.788 and 0.736, respectively (p?<?0.05). With a specificity of 90% as a diagnostic criterion, the value of hs-cTnT to evaluate LVH, LVEF?Conclusions In CKD non-dialysis population, hs-cTnT and NT-proBNP were valuable for evaluating LVH, left ventricular systolic dysfunction and left ventricular diastolic dysfunction.     

Leukocyte-depleted blood cardioplegia reduces cardiac troponin T release in patients undergoing coronary artery bypass grafting.

OBJECTIVE: Activated neutrophils have been implicated in reperfusion injury of the myocardium. Leukocyte depletion at reperfusion may contribute to better myocardial protection during cardiac surgery. We tested the efficacy of leukocyte-depleted blood cardioplegia in reducing myocardial injury during coronary artery bypass grafting. METHODS: Subjects were 27 patients undergoing elective coronary artery bypass grafting divided into controls (perfused with nonfiltered blood cardioplegia, n = 12) and those undergoing leukocyte-depleted blood cardioplegia (n = 15). Oxygenated blood mixed with a potassium crystalloid cardioplegic solution was delivered through the aortic root at every 30 minutes during cardiac arrest and terminal warm blood was administered before aortic declamping in both groups. In leukocyte depletion, blood was filtered prior to the mixture with crystalloid solution in the cardioplegic reservoir. RESULTS: Patient profiles did not differ significantly between groups, nor did systemic leukocyte count during or after surgery despite more than 81% removal of leukocytes in cardioplegic delivery. No consistent differences between groups in creatine kinase or creatine kinase-MB were seen up to 18 hours after surgery. Peak troponin T levels were significantly lower in the leukocyte-depleted blood cardioplegia group (0.52 +/- 0.13 ng/ml), however, than in controls (3.85 +/- 0.85 ng/ml). CONCLUSION: We concluded that leukocyte-depleted blood cardioplegia reduces the release of cardiac troponin T in patients undergoing elective coronary artery bypass grafting and may produce better myocardial protection in patients with impaired cardiac function or a damaged myocardium.     

缺血性心脏病患者非心脏手术围术期心肌肌钙蛋白I的动态变化

目的　观察心肌肌钙蛋白I(cTnI)在缺血性心脏病患者非心脏手术围术期的动态变化与临床预后的关系。方法　 10 0例ASAⅡ～Ⅲ级择期非心脏手术患者 ,诊断合并缺血性心脏病 ,分别于术前、麻醉诱导后、术毕和术后 6h进行血清cTnI的动态检测 ,记录围术期心电改变和心脏事件的发生情况。以术前cTnI≥ 0 3μg/L为阳性 ,将病人分为阴性组和阳性组。 结果　两组患者术毕及术后 6hcTnI均显著高于术前 (P <0 0 5或P <0 0 1) ;术毕及术后 6hcTnI阳性组显著高于阴性组(P <0 0 5 )。阳性组术后心电改变发生率明显高于阴性组 (P <0 0 5 ) ;术后心脏事件发生率亦显著高于阴性组 (P <0 0 1)。结论　cTnI是判断心肌损伤的可靠指标 ,术前cTnI升高对识别围术期高危缺血性心脏病患者及判断预后有较好的临床价值     

缺血性心脏病患者非心脏手术围术期心肌肌钙蛋白Ⅰ的动态变化

目的观察心肌肌钙蛋白Ⅰ(cTnI)在缺血性心脏病患者非心脏手术围术期的动态变化与临床预后的关系.方法100例ASAⅡ～Ⅲ级择期非心脏手术患者,诊断合并缺血性心脏病,分别于术前、麻醉诱导后、术毕和术后6 h进行血清cTnI的动态检测,记录围术期心电改变和心脏事件的发生情况.以术前cTnI≥0.3 μg/L为阳性,将病人分为阴性组和阳性组.结果两组患者术毕及术后6 h cTnI均显著高于术前(P＜0.05或P＜0.01);术毕及术后6 h cTnI阳性组显著高于阴性组(P＜0.05).阳性组术后心电改变发生率明显高于阴性组(P＜0.05);术后心脏事件发生率亦显著高于阴性组(P＜0.01).结论cTnI是判断心肌损伤的可靠指标,术前cTnI升高对识别围术期高危缺血性心脏病患者及判断预后有较好的临床价值.     

Long-term prognostic value of asymptomatic cardiac troponin T elevations in patients after major vascular surgery.

BACKGROUND: Cardiac troponin T (cTnT) is a sensitive and specific marker for myocardial injury, but elevations of cTnT without clinical evidence of ischemia and persistent or new electrocardiographic (ECG) abnormalities are common in patients undergoing major vascular surgery. We explored the long-term prognostic value of cTnT levels in these patients. METHODS: A follow-up study was conducted between 1996-2000 in 393 patients who underwent successful aortic or infrainguinal vascular surgery and routine sampling of cTnT. Patients were followed until May 2003 (median of 4 years [25th-75th percentile, 2.8-5.3 years]). Total creatine kinase (CK), CK-MB, and cTnT were routinely screened in all patients, and included sampling after surgery and the mornings of postoperative days 2, 3 and 7. Electrocardiograms were also routinely evaluated for sign of ischemia. An elevated cTnT was defined as serum concentrations >/=0.1 ng/ml in any of these samples. All-cause mortality was evaluated during long-term follow-up. RESULTS: Eighty patients (20%) had late death. The incidence of all-cause mortality (41% vs. 17%; p<0.001) was significantly higher in patients with an elevated cTnT level compared to patients with normal cTnT. After adjustment for baseline clinical characteristics, the association between an elevated cTnT level and increased incidence of all-cause mortality (adjusted hazard ratio, 1.9; 95% CI, 1.1-3.1) persisted. Elevated cTnT had significant prognostic value in patients with and without renal dysfunction, abnormal levels of CK-MB, and in patients with transient ECG abnormalities. CONCLUSIONS: Elevated cTnT levels are associated with an increased incidence of all-cause mortality in patients undergoing major vascular surgery.     

High-sensitivity cardiac troponin T in young,healthy adults undergoing non-cardiac surgery

Background

It is unclear if isolated postoperative cardiac-troponin elevation, often referred to as myocardial injury, represents a pathological event, as control studies in otherwise healthy adults are lacking.

Minor cardiac troponin T release in patients undergoing coronary artery bypass graft surgery on a beating heart

OBJECTIVES: To determine whether and to what extent coronary artery bypass graft (CABG) surgery without extracorporeal circulation is associated with cardiac troponin T (TnT) release. DESIGN: Prospective study. SETTING: A single university hospital. PARTICIPANTS: Twenty-three patients scheduled for minimally invasive CABG surgery. Sixteen patients received one coronary anastomosis, and seven received two. INTERVENTIONS: TnT and creatine kinase-MB (CK-MB) levels were determined immediately before induction of anesthesia (baseline) and at 0, 12, and 24 hours after surgery. Hemodynamic measurements were made, and 5-lead electrocardiograms with continuous automated ST-segment trends were analyzed. MEASUREMENTS AND MAIN RESULTS: All patients had a good cardiac outcome. Median cumulative coronary artery occlusion time was 27 minutes (range, 10 to 49 minutes). TnT levels were undetectable in 91.3% of patients at baseline when a detection limit of 0.01 ng/mL was employed. TnT and CK-MB showed significant elevations at 12 and 24 hours versus baseline. Postoperatively, TnT was detectable in 91.3% of patients, and 17.4% suffered minor myocardial damage, as evidenced by an abnormal increase in TnT greater than 0.2 ng/mL, excluding those exhibiting myocardial infarction. ST segment changes developed in seven patients, persisting for 13.0 minutes (range, 9.5 to 15.8 minutes) and disappearing immediately after coronary artery clamp release. There were no significant correlations between cumulative coronary occlusion time and peak TnT or CK-MB levels. CONCLUSIONS: TnT was detected after surgery in most patients, and significant TnT levels indicative of myocardial injury (>0.2 ng/mL) were detected in only 17% of patients, probably as a result of brief periods of coronary artery occlusion.     

Prognostic value of postoperative high-sensitivity troponin T in patients with different stages of kidney disease undergoing noncardiac surgery

Background

Emerging evidence suggests that postoperative troponin release is a strong and independent predictor of short-term mortality. However, evaluating elevated troponins in patients with chronic kidney disease (CKD) is still controversial and is often disregarded. This study examines morbidity along with short- and long-term mortality risk associated with elevated high-sensitivity troponin T (hsTnT) in patients with different stages CKD undergoing noncardiac surgery.