Статья
ПЕРИОПЕРАЦИОННАЯ ОЦЕНКА ТРОПОНИНА ПРИ НЕКАРДИАЛЬНЫХ ОПЕРАЦИЯХ: ЕСТЬ ЛИ ТАКАЯ НЕОБХОДИМОСТЬ?
При некардиальных операциях частота неблагоприятных кардиальных событий (инфаркт миокарда, летальный исход) составляет примерно от 2% до 3% от всего числа пациентов, однако повышение тропонинов отмечают гораздо чаще – от 5% до 25% больных. Такое изолированное повышение тропонинов при отсутствии критериев инфаркта миокарда называют также «повреждение миокарда после некардиальной хирургии». Такое состояние связано с неблагоприятным прогнозом как непосредственно после операции, так и в отдаленном периоде. Представлены современные данные по скринингу уровня тропонина после операций, и предложения по лечению больных с его повышением. Рассмотрены различные точки зрения по данному вопросу, что позволяет более полно высветить проблему и помочь клиницисту в ведении этой категории пациентов.
1. Weiser T.G., Regenbogen S.E., Thompson K.D., et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008;372:139-44.
2. Fleisher L.A., Fleischmann K.E., Auerbach A.D., et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol 2014;64:e77e137.
3. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment andmanagement. The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014;35:2383-431.
4. Beckman J.A. Postoperative troponin screening: a cardiac Cassandra? Circulation 2013; 127:2253-6.
5. Finks J.F., Osborne N.H., Birkmeyer J.D. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 2011;364:2128-37.
6. Devereaux P.J., Yang H., Yusuf S., et al. Effects of extended release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008;371:1839-47
7. Sheth T., Chan M., Butler C., et al. Coronary Computed Tomographic Angiography and Vascular Events in Noncardiac Surgery Patients Cohort Evaluation Study Investigators. Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study. BMJ 2015;350:h1907. doi: 10.1136/bmj.h1907.
8. McFalls E.O., Ward H.B., Moritz T.E., et al. Predictors and outcomes of a perioperative myocardial infarction following elective vascular surgery in patients with documented coronary artery disease: results of the CARP trial. Eur Heart J 2008;29:394-401.
9. Sumin A.N.The assessment and reduction of cardiac events risk in noncardiac operations: is there a need for review of recommendations? Ration Pharmacother Cardiol 2013;5:570-6. Russian (Сумин А.Н. Оценка и снижение риска кардиальных осложнений при некардиальных операциях: есть ли необходимость пересмотра рекомендаций? Рациональная Фармакотерапия в Кардиологии 2013;5:570-6).
10. Samoylenko V.V., Shevchenko O.P., Burtsev V.I. Statins use in the perioperative period according to the evidence-based medicine. Ration Pharmacother Cardiol 2014;5:548-553. Russian (Самойленко В.В., Шевченко О.П., Бурцев В.И. Применение статинов в периоперационном периоде с позиций доказательной медицины. Рациональная Фармакотерапия в Кардиологии 2014;5:548-553).
11. Botto F., Alonso-Coello P., Chan M.T., et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30day outcomes. Anesthesiology 2014;120:564-78.
12. Foucrier A., Rodseth R., Aissaoui M., et al. The long-term impact of early cardiovascular therapy intensification for postoperative troponin elevation after major vascular surgery. Anesth Analg 2014;119:1053-63.
13. Horr S., Reed G., Menon V. Troponin elevation after noncardiac surgery: Significance and management CCJM 2015;82(9):595-602.
14. Cohn S. Postoperative troponin surveillance: A diagnostic dilemma. CCJM 2015;82(9):603-5.
15. Mandell B. Perioperative MI: Data, practice, and questions. CCJM 2015;82(9):552-4.
16. Lee T.H., Marcantonio E.R., Mangione C.M., et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100:1043-9.
17. Landesberg G., Shatz V., Akopnik I., et al. Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with longterm survival after major vascular surgery. J Am Coll Cardiol 2003;42:1547-54.
18. Devereaux P.J., Goldman L., Cook D.J., et al. Perioperative cardiac events in patients undergoing non-cardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ 2005; 173:627-34.
19. Devereaux P.J., Xavier D., Pogue J., et al. Characteristics and shortterm prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med 2011;154:523-8.
20. Devereaux P.J., Chan M.T., Alonso-Coello P., et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA 2012;307:2295-304.
21. Feringa H.H., Bax J.J., Boersma E., et al. High-dose beta-blockers and tight heart rate control reduce myocardial ischemia and troponin T release in vascular surgery patients. Circulation 2006;114:I344-I349.
22. Landesberg G. The pathophysiology of perioperative myocardial infarction: facts and perspectives. J Cardiothorac Vasc Anesth 2003;17:90-100.
23. Nelson A.H., Fleisher L.A., Rosenbaum S.H. Relationship between postoperative anemia and cardiac morbidity in high-risk vascular patients in the intensive care unit. Crit Care Med 1993; 21:860-6.
24. Landesberg G., Beattie W.S., Mosseri M., et al. Perioperative myocardial infarction. Circulation 2009;119:2936-44.
25. Ellis S.G., Hertzer N.R., Young J.R., Brener S. Angiographic correlates of cardiac death and myocardial infarction complicating major nonthoracic vascular surgery. Am J Cardiol 1996; 77:1126-8.
26. van Waes J.A., Nathoe H.M., de Graaff J.C., et al. Myocardial injury after noncardiac surgery and its association with short-term mortality. Circulation 2013;127:2264-71.
27. Thygesen K., Alpert J.S., Jaffe A.S., et al. Third universal definition of myocardial infarction. Circulation 2012;126:2020-35.
28. Ottani F., Galvani M., Nicolini F.A., et al. Elevated cardiac troponin levels predict the risk of adverse outcome in patients with acute coronary syndromes. Am Heart J 2000;140:917-27.
29. Steen H., Giannitsis E., Futterer S., et al. Cardiac troponin T at 96 hours after acute myocardial infarction correlates with infarct size and cardiac function. J Am Coll Cardiol 2006;48:2192-4.
30. Vasile V.C., Babuin L., Giannitsis E., et al. Relationship of MRI-determined infarct size and cTnI measurements in patients with ST-elevation myocardial infarction. Clin Chem 2008; 54:617-9.
31. Sabatine M.S., Morrow D.A., de Lemos J.A., et al. Detection of acute changes in circulating troponin in the setting of transient stress test-induced myocardial ischaemia using an ultrasensitive assay: re-
32. Siriwardena M., Campbell V., Richards A.M., Pemberton C.J. Cardiac biomarker responses to dobutamine stress echocardiography in healthy volunteers and patients with coronary artery disease. Clin Chem 2012;58:1492-4.
33. Turer A.T., Addo T.A., Martin J.L., et al. Myocardial ischemia induced by rapid atrial pacing causes troponin T release detectable by a highly sensitive assay: insights from a coronary sinus sampling study. J Am Coll Cardiol 2011;57:2398-405.
34. Levy M., Heels-Ansdell D., Hiralal R., et al. Prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after noncardiac surgery: a systematic review and meta-analysis. Anesthesiology 2011;114:796-806.
35. Garcia S., Marston N., Sandoval Y., et al. Prognostic value of 12-lead electrocardiogram and peak troponin I level after vascular surgery. J Vasc Surg 2013;57:166-72.
36. Beattie W.S., Karkouti K., Tait G., et al. Use of clinically based troponin underestimates the cardiac injury in non-cardiac surgery: a single-centre cohort study in 51,701 consecutive patients. Can J Anaesth 2012;59:1013-22.
37. Gallino A., Aboyans V., Diehm C., et al.; European Society of Cardiology Working Group on Peripheral Circulation. Non-coronary atherosclerosis. Eur Heart J. 2014;35(17):1112-9.
38. Oganov R.G. Vascular comorbidity: general approaches to prevention and treatment. Ration Pharmacother Cardiol 2015;1:4-7. Russian (Оганов Р.Г. Сосудистая коморбидность: общие подходы к профилактике и лечению. Рациональная Фармакотерапия в Кардиологии 2015;1:4-7).
39. Barbarash L.S., Sumin A.N., Evdokimov D.O., et al. Role of coronary angiography in decreasing cardiac complications rate during vascular operations. Angiologiya i Sosudistaya Khirurgiya 2012;18(4):3341. Russian (Барбараш Л.С., Сумин А.Н., Евдокимов Д.О. и др. Роль клинической оценки и коронароангиографии в снижении числа кардиальных осложнений при сосудистых операциях промежуточного и высокого риска. Ангиология и Сосудистая Хирургия 2012;18(4):33-41).
40. Gupta P.K., Gupta H., Sundaram A., et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation 2011;124:381-7.
41. Bilimoria K.Y., Liu Y., Paruch J.L., et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg 2013;217:833-42.
42. Davis C., Tait G., Carroll J., et al. The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients. Can J Anaesth 2013;60:855-63.
43. Monaco M., Stassano P., Di Tommaso L., et al. Systematic strategy of prophylactic coronary angiography improves long-term outcome after major vascular surgery in mediumto high-risk patients. A prospective, randomized study. JACC 2009;54:989-96
44. Illuminati G., Ricco J.-B., Greco C. et al. Systematic preoperative coronary angiography and stenting improves postoperative results of carotid endarterectomy in patients with asymptomatic coronary artery disease: a randomised controlled trial. Eur J Vasc Endovasc Surg. 2010;39(2):139-45.
45. Sumin A.N., Barbarash O.L. Contradictions in the tactics evaluation and reduce the risk of cardiac complications in non-cardiac operations: non-invasive stress tests. Serdce 2011;4:199-206. Russian (Сумин А.Н., Барбараш О.Л. Противоречия в тактике оценки и снижения риска кардиологических осложнений при некардиальных операциях: неинвазивные стресс-тесты. Сердце 2011;4:199-206).
46. Frolovicheva I.S., Mozzhukhina N.V., Chomakhidze P.Sh., et al. Evaluation of risk for cardiovascular complications of non-cardiac interventions: general recommendations and clinical observations. Kardiologija i Serdechno-Sosudistaja Hirurgija 2013;3:94-100. Russian (Фроловичева И.С., Мозжухина Н.В., Чомахидзе П.Ш. и др. Оценка риска развития сердечно-сосудистых осложнений при некардиологических вмешательствах: основные рекомендации и клинические наблюдения. Кардиология и Сердечно-Сосудистая Хирургия 2013;3:94-100).
47. Vachyov A.N., Schukin Yu.V., Surkova E.A., Dmitriev O.V. Medicamental management of CHD cases before carotid endarterectomy. Kompleksnye Problemy Serdechno-Sosudistyh Zabolevanij 2013;4:8387. Russian (Вачёв А.Н., Щукин Ю.В., Суркова Е.А., Дмитриев О.В. Медикаментозное ведение пациентов с ИБС перед выполнением операции каротидной эндартерэктомии. Комплексные проблемы сердечно-сосудистых заболеваний 2013;4:83-87).
48. Rodseth R., Devereaux P.J. Should we measure troponin routinely in patients after vascular surgery? American College of Cardiology. Available at: www.acc.org/latest-in-cardiology/articles/2014/07/18/14/46/shouldwe-measure-troponin-routinely-in-patients-after-vascularsurgery?w_ nav=LC. Accessed by August 5, 2015.
49. John J., Woodward D.B., Wang Y., et al. Troponin-I as a prognosticator of mortality in severe sepsis patients. J Crit Care 2010;25:270-5.
50. Sandhu R., Aronow W.S., Rajdev A., et al. Relation of cardiac troponin I levels with in-hospital mortality in patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Am J Cardiol 2008;102:632-4.
51. de Lemos J.A., Drazner M.H., Omland T., et al. Association of troponin T detected with a highly sensitive assay and cardiac structure and mortality risk in the general population. JAMA 2010;304:2503-12.
52. Chernyavsky A.M., Karpenko A.A., Chernyavsky M.A., et al. Cardiac events and their prevention in abdominal aortic aneurysm surgery. Kompleksnye Problemy Serdechno-Sosudistyh Zabolevanij 2013;4:88-93. Russian (Чернявский А.М., Карпенко А.А., Чернявский М.А. и др.. Кардиальные осложнения и их профилактика в хирургии аневризм брюшной аорты. Комплексные проблемы сердечно-сосудистых заболеваний 2013;4:88-93).
53. Sumin A.N., Korok E.V., Panfilov S.D., et al. Preventive myocardial revascularisation before abdominal aortic interventions: long-term results. Rossijskij Kardiologicheskij Zhurnal 2013;6(104):11-16. Russian (Сумин А.Н., Корок Е.В., Панфилов С.Д. и др.. Использование стратегии с превентивной реваскуляризацией миокарда перед операциями на брюшной аорте: отдаленные результаты. Российский кардиологический журнал 2013;6(104):11-16).