术后脑利钠肽浓度与体外循环心脏手术的术后12个月的全因死亡率相关
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Absolute Postoperative B-Type Natriuretic Peptide Concentrations, but Not Their General Trend, Are Associated With 12-Month, All-Cause Mortality After On-Pump Cardiac Surgery
背景与目的
脑利钠肽是心脏手术后死亡率的预测因子。然而，既往有限的和异质性的研究集中在手术后3至5天的峰值浓度，这可能不会为临床医生提供早期的帮助。经过初步分析确定术后第一天脑利钠肽的预测价值后，我们探讨了术后第二天脑利钠肽浓度、第二天脑利钠肽浓度与第一天脑利钠肽浓度之间的关系以及从术后第一天到第二天脑利钠肽的变化（即Δ脑利钠肽）和术后12个月的全因死亡率。
方 法
我们连续纳入了体外循环心脏手术的患者对其收集数据进行了观察性前瞻性二次分析。我们分析了术后第一天和第二天的生物标志物。Δ脑利钠肽定义为术后第二天脑利钠肽减去术后第一天脑利钠肽。主要结局为12个月全因死亡率。次要结局是12个月主要不良心脏事件（MACE）和12个月全因死亡率的综合。MACE定义为非致死性心脏停搏，心肌梗死和充血性心力衰竭。脑利钠肽与通过受试者手术特征曲线以及单变量和多变量逻辑回归检查的结果之间的关系，来调整EuroSCORE II，阻断时间和第一天肌钙蛋白T。
结 果
我们初步分析了1199例患者术后第一天的脑利钠肽。在分析中需要检测术后第二天（N = 708）的脑利钠肽，测定脑利钠肽的变化，我们观察到66例（9.3％）死亡，48例 (6.8%)不良心脏事件，104（14.7％）例死亡和/或不良心脏事件。术后第一天和第二天的脑利钠肽以每100ng/L增加，这为12个月全因死亡率的显著独立预测因子（校正比值比[AOR]分别为1.040[95%CI，1.019-1.065 ]和1.064[95%CI，1.031-1.105]）。当彼此结合时，第一天脑利钠肽不明显增加（AOR，1.021 [95% CI，0.995–1.048]），而第二天脑利钠肽明显增加（AOR，1.046 [ 95% CI，1.008–1.091]），在单变量（OR，0.977 [95％CI，0.951-1.007 ]）或多变量分析（aOR，0.989 [95％CI，0.962-1.021]）中，Δ脑利钠肽以每100ng/L的增加与12个月全因死亡率无关。
结 论
术后第一天和第二天脑利钠肽的绝对浓度是术后12个月全因死亡率的独立预测因子。当模型合并时，术后第二天脑利钠肽可预测术后12个月全因死亡率。脑利钠肽从术后第一天到第二天的变化虽然直观且特殊，但这是一个复杂的变量，不应该常规的用于全因死亡率的预测。
原始文献摘要
Eckhard Mauermann,Daniel Bolliger,Jens Fassl,et al.Absolute Postoperative B-Type Natriuretic Peptide Concentrations, but Not Their General Trend,Are Associated With 12-Month, All-Cause Mortality After On-Pump Cardiac Surgery.Anesthesia & Analgesia.125(3):753-761, September 2017.
BACKGROUND: B-type natriuretic peptide (BNP) is a predictor of mortality after on-pump cardiac surgery.However,previous limited and heterogeneous studies have focused on peak concentrations at 3 to 5 days after surgery and may not offer clinicians much help in early decision-making.After confirming the predictive value of first-postoperative-day BNP in a preliminary analysis,we explored the association between isolated second-postoperative-day BNP concentrations,second-day BNP concentrations in conjunction with first-day BNP concentrations, and the change in BNP (ie,ΔBNP) from the first to the second postoperative day and 12-month,all-cause mortality.
METHODS: We included consecutive patients undergoing on-pump cardiac surgery in this observational, secondary analysis of prospectively collected data.We analyzed biomarkers on the first and second postoperative day.ΔBNP was defined as BNP on the second postoperative day minus BNP on the first postoperative day.The primary end point was 12-month,all-cause mortality. The secondary end point was a composite of major adverse cardiac events (MACEs) at 12 months and/or all-cause mortality at 12 months.MACE was defined as nonfatal cardiac arrest, myocardial infarction,and congestive heart failure.The association between BNP and outcomes was examined by receiver operating characteristic curves,as well as univariate and multivariable logistic regression,adjusting for the EuroSCORE II,cross-clamp time,and firstpostoperative-day troponin T.
RESULTS: We included 1199 patients in the preliminary analysis focused on BNP on postoperative day 1.In the analyses examining BNP variables requiring second-postoperative-day BNP measurement (n = 708),we observed 66 (9.3%) deaths,48 (6.8%) MACE,and 104 (14.7%) deaths and/or MACE. Both first- and second-postoperative-day BNP were significant independent predictors of all-cause,12-month mortality per 100 ng/L increase (adjusted odds ratio[aOR],1.040 [95% confidence interval (CI),1.019–1.065] and 1.064 [95% CI,1.031–1.105] respectively).When used in conjunction with one another, first-day BNP was not significant (aOR,1.021 [95% CI, 0.995–1.048]), while second-day BNP remained significant (aOR, 1.046 [95% CI, 1.008–1.091]).The ΔBNP per 100 ng/L increase was not associated with 12-month,allcause mortality in the univariable (OR, 0.977 [95% CI, 0.951–1.007]) or multivariable analysis(aOR, 0.989 [95% CI, 0.962–1.021]).
CONCLUSIONS:Both absolute concentrations of first-and second- postoperative-day BNP are independent predictors of 12-month,all-cause mortality.When modeled together, secondpostoperative-day BNP is more predictive of 12-month,all-cause mortality. Although intuitively appealing,the change in BNP from the first to the second postoperative day is a complex variable and should not routinely be used for prognostication.
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