Abstract：
BACKGROUND: An elevated cardiac troponin concentration is a prognostic factor for perioperative cardiac morbidity and mortality. In elderly patients undergoing emergency abdominal surgery, frailty is a recognized risk factor, but little is known about the prognostic value of cardiac troponin in these vulnerable patients. Therefore, we investigated the prognostic significance of elevated high-sensitivity cardiac troponin T (hs-cTnT) concentration and frailty in a cohort of elderly patients undergoing emergency abdominal surgery.
METHODS: We included consecutive patients ≥75 years of age who presented for emergency abdominal surgery, defined as abdominal pathology requiring surgery within 72 hours, in a university hospital in Norway. Patients who underwent vascular procedures or palliative surgery for inoperable malignancies were excluded. Preoperatively, frailty was assessed using the Clinical Frailty Scale (CFS), and blood samples were measured for hs-cTnT. We evaluated the predictive power of CFS and hs-cTnT concentrations using receiver operating characteristic (ROC) curves and Cox proportional hazard regression with 30-day mortality as the primary outcome. Secondary outcomes included (1) a composite of 30-day all-cause mortality and major adverse cardiac event (MACE), defined as myocardial infarction, nonfatal cardiac arrest, or coronary revascularization; and (2) 90-day mortality.
RESULTS: Of the 210 screened and 156 eligible patients, blood samples were available in 146, who were included. Troponin concentration exceeded the 99th percentile upper reference limit (URL) in 83% and 89% of the patients pre- and postoperatively. Of the participants, 53% were classified as vulnerable or frail (CFS ≥4). The 30-day mortality rate was 12% (18 of 146). Preoperatively, a threshold of hs-cTnT ≥34 ng/L independently predicted 30-day mortality (hazard ratio [HR] 3.14, 95% confidence interval [CI], 1.13-9.45), and the composite outcome of 30-day mortality and MACE (HR 2.58, 95% CI, 1.07-6.49). In this model, frailty (continuous CFS score) also independently predicted 30-day mortality (HR 1.42, 95% CI, 1.01-2.00) and 30-day mortality or MACE (HR 1.37, 95% CI, 1.02-1.84). The combination of troponin and frailty, 0.14 × hs-cTnT +4.0 × CFS, yielded apparent superior predictive power (area under the receiver operating characteristics curve [AUC] 0.79, 95% CI, 0.68-0.88), compared to troponin concentration (AUC 0.69, 95% CI, 0.55-0.83) or frailty (AUC 0.69, 95% CI, 0.57-0.82) alone.
CONCLUSIONS: After emergency abdominal surgery in elderly patients, increased preoperative troponin concentration and frailty were independent predictors of 30-day mortality. The combination of increased troponin concentration and frailty seemed to provide better prognostic information than troponin or frailty alone. These results must be validated in an independent sample.
METHODS: We included consecutive patients ≥75 years of age who presented for emergency abdominal surgery, defined as abdominal pathology requiring surgery within 72 hours, in a university hospital in Norway. Patients who underwent vascular procedures or palliative surgery for inoperable malignancies were excluded. Preoperatively, frailty was assessed using the Clinical Frailty Scale (CFS), and blood samples were measured for hs-cTnT. We evaluated the predictive power of CFS and hs-cTnT concentrations using receiver operating characteristic (ROC) curves and Cox proportional hazard regression with 30-day mortality as the primary outcome. Secondary outcomes included (1) a composite of 30-day all-cause mortality and major adverse cardiac event (MACE), defined as myocardial infarction, nonfatal cardiac arrest, or coronary revascularization; and (2) 90-day mortality.
RESULTS: Of the 210 screened and 156 eligible patients, blood samples were available in 146, who were included. Troponin concentration exceeded the 99th percentile upper reference limit (URL) in 83% and 89% of the patients pre- and postoperatively. Of the participants, 53% were classified as vulnerable or frail (CFS ≥4). The 30-day mortality rate was 12% (18 of 146). Preoperatively, a threshold of hs-cTnT ≥34 ng/L independently predicted 30-day mortality (hazard ratio [HR] 3.14, 95% confidence interval [CI], 1.13-9.45), and the composite outcome of 30-day mortality and MACE (HR 2.58, 95% CI, 1.07-6.49). In this model, frailty (continuous CFS score) also independently predicted 30-day mortality (HR 1.42, 95% CI, 1.01-2.00) and 30-day mortality or MACE (HR 1.37, 95% CI, 1.02-1.84). The combination of troponin and frailty, 0.14 × hs-cTnT +4.0 × CFS, yielded apparent superior predictive power (area under the receiver operating characteristics curve [AUC] 0.79, 95% CI, 0.68-0.88), compared to troponin concentration (AUC 0.69, 95% CI, 0.55-0.83) or frailty (AUC 0.69, 95% CI, 0.57-0.82) alone.
CONCLUSIONS: After emergency abdominal surgery in elderly patients, increased preoperative troponin concentration and frailty were independent predictors of 30-day mortality. The combination of increased troponin concentration and frailty seemed to provide better prognostic information than troponin or frailty alone. These results must be validated in an independent sample.
摘要：
背景：心肌肌钙蛋白浓度升高是围手术期心脏病发病率和死亡率的预后因素。在接受紧急腹部手术的老年患者中，虚弱是公认的风险因素，但对这些易感患者的心肌肌钙蛋白的预后价值知之甚少。因此,在接受急诊腹部手术的老年患者队列中,我们调查了高敏肌钙蛋白T(hs-cTnT)浓度升高和虚弱的预后意义.
方法：我们纳入了接受紧急腹部手术的年龄≥75岁的连续患者，定义为需要在72小时内进行手术的腹部病理，在挪威的一所大学医院。排除因无法手术的恶性肿瘤而接受血管手术或姑息性手术的患者。术前,使用临床虚弱量表(CFS)评估虚弱，并测定血液样本的hs-cTnT。我们使用受试者工作特征（ROC）曲线和Cox比例风险回归，以30天死亡率为主要结果，评估了CFS和hs-cTnT浓度的预测能力。次要结局包括（1）30天全因死亡率和主要不良心脏事件（MACE）的复合，定义为心肌梗塞，非致命的心脏骤停,或冠状动脉血运重建;和(2)90天死亡率。
结果：在210名筛查和156名符合条件的患者中，146人的血液样本被纳入其中.肌钙蛋白浓度超过第99百分位数参考上限（URL）的83％和89％的患者术前和术后。在参与者中，53%被归类为脆弱或虚弱(CFS≥4)。30天死亡率为12％（146例中的18例）。术前,hs-cTnT≥34ng/L的阈值独立预测30天死亡率(风险比[HR]3.14，95%置信区间[CI]，1.13-9.45),以及30天死亡率和MACE的复合结局（HR2.58，95％CI，1.07-6.49）。在这个模型中,虚弱(连续CFS评分)也独立预测30天死亡率(HR1.42,95%CI,1.01-2.00)和30天死亡率或MACE(HR1.37,95%CI,1.02-1.84)。肌钙蛋白和虚弱的结合，0.14×hs-cTnT+4.0×CFS，产生了明显的预测能力(接受者工作特征曲线下面积[AUC]0.79，95%CI，0.68-0.88)，与单独的肌钙蛋白浓度（AUC0.69，95％CI，0.55-0.83）或虚弱（AUC0.69，95％CI，0.57-0.82）相比。
结论：老年患者行紧急腹部手术后，术前肌钙蛋白浓度升高和虚弱是30日死亡率的独立预测因素.肌钙蛋白浓度增加和虚弱的结合似乎比单独的肌钙蛋白或虚弱提供了更好的预后信息。这些结果必须在独立样本中进行验证。
方法：我们纳入了接受紧急腹部手术的年龄≥75岁的连续患者，定义为需要在72小时内进行手术的腹部病理，在挪威的一所大学医院。排除因无法手术的恶性肿瘤而接受血管手术或姑息性手术的患者。术前,使用临床虚弱量表(CFS)评估虚弱，并测定血液样本的hs-cTnT。我们使用受试者工作特征（ROC）曲线和Cox比例风险回归，以30天死亡率为主要结果，评估了CFS和hs-cTnT浓度的预测能力。次要结局包括（1）30天全因死亡率和主要不良心脏事件（MACE）的复合，定义为心肌梗塞，非致命的心脏骤停,或冠状动脉血运重建;和(2)90天死亡率。
结果：在210名筛查和156名符合条件的患者中，146人的血液样本被纳入其中.肌钙蛋白浓度超过第99百分位数参考上限（URL）的83％和89％的患者术前和术后。在参与者中，53%被归类为脆弱或虚弱(CFS≥4)。30天死亡率为12％（146例中的18例）。术前,hs-cTnT≥34ng/L的阈值独立预测30天死亡率(风险比[HR]3.14，95%置信区间[CI]，1.13-9.45),以及30天死亡率和MACE的复合结局（HR2.58，95％CI，1.07-6.49）。在这个模型中,虚弱(连续CFS评分)也独立预测30天死亡率(HR1.42,95%CI,1.01-2.00)和30天死亡率或MACE(HR1.37,95%CI,1.02-1.84)。肌钙蛋白和虚弱的结合，0.14×hs-cTnT+4.0×CFS，产生了明显的预测能力(接受者工作特征曲线下面积[AUC]0.79，95%CI，0.68-0.88)，与单独的肌钙蛋白浓度（AUC0.69，95％CI，0.55-0.83）或虚弱（AUC0.69，95％CI，0.57-0.82）相比。
结论：老年患者行紧急腹部手术后，术前肌钙蛋白浓度升高和虚弱是30日死亡率的独立预测因素.肌钙蛋白浓度增加和虚弱的结合似乎比单独的肌钙蛋白或虚弱提供了更好的预后信息。这些结果必须在独立样本中进行验证。
