180529 非心臓手術後のPMIjikeimasuika.jp/icu_st/180529.pdfStrengths and Limitations...

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Transcript of 180529 非心臓手術後のPMIjikeimasuika.jp/icu_st/180529.pdfStrengths and Limitations...

Page 1: 180529 非心臓手術後のPMIjikeimasuika.jp/icu_st/180529.pdfStrengths and Limitations 8Strengths9 • *$FTR[^V]SX\SZYN&J,OB>D •PMIF2-@L# N =F+ • •) Ghs-cTnTG K :PMID %4

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MI�"��#$�$• ACS�����'�� !$���• � !$��������"��#$�$� ��

2009/12/22 ICU��%����& : Circulation 2006 ; 113 : 2335-2362

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PMI(��

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Type1 Type2

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CMAJ 2005 ; 173(6) : 627-34

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Cardiovasc Diagn Ther 2017 ; 7(4) : 348-58Journal of the American College of Cardiology 2014 ; 63(20) : 2079-2087

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The American Journal of Medicine 2013 ; 126(9) : 789-97

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PMI��������

• POISE trial �2008�

• VISION study �2014�

• VISION study �2017�

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Characteristics and Short-Term Prognosis of PerioperativeMyocardial Infarction in Patients Undergoing Noncardiac Surgery

Annals of Internal Medicine 2011 ; 154 : 523-528

POISE trial

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POISE trial• 415 � (5.0%) �PMI 65%�����• ST���31.3% ��T��21.7% ST���10.6%��

Annals of Internal Medicine 2011 ; 154 : 523-528

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POISE trial• PMI��$30����%11.6%�no PMI��#%2.2%*p<0.001+

• �� PMI%CPA����! ���� PMI%����! �

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Annals of Internal Medicine 2011 ; 154 : 523-528

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POISE trial• �� HR10�����PMI �����31%��

Annals of Internal Medicine 2011 ; 154 : 523-528

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A Large, International, Prospective Cohort Study Establishing Diagnostic Criteria, Characteristics, Predictors, and 30-day Outcomes

Anesthesiology 2014 ; 120 : 564-78

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VISION study (2014)

• MINS 1,194� 8.0%�

• MINS30���������(adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08)

Anesthesiology 2014 ; 120 : 564-78

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VISION study (2014)• ��������eGFR������!�� ��• eGFR↓�MINS��!$#"↑• ��eGFR�30 �����������������%P=0.48&

Anesthesiology 2014 ; 120 : 564-78

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VISION study (2014)

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Anesthesiology 2014 ; 120 : 564-78

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Associa'on of Postopera've High-Sensi'vity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Pa'ents Undergoing Noncardiac Surgery

JAMA. 2017 ; 317(16) : 1642-51

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VISION study (2017)

• Peak hs-TnT 20-65 ng/L→3.0%• Peak hs-TnT 65-1000 ng/L→9.1%• Peak hs-TnT >=1000 ng/L→29.6%

JAMA. 2017 ; 317(16) : 1642-51

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VISION study (2017)

• MINS�17.9%• MINS�Major

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JAMA. 2017 ; 317(16) : 1642-51

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POISE VISION 2014 VISION 2017�2 2002�d2007� 2007�d2011� 2008�d2013��/ 190�/923Q� 12�/98Q� 23�/913Q�

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Introduction

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Aim

• �����*�")PMI.+/-,��• ���&PMI screening program*��• ��0� 'hs-cTnT'��• screening program#PMI*%'����#!) 3

• PMI$� 130�����1���2$'��*�()

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Methods>�9?• [`W]��,;H<�4�5P�CO�0• 5�24!:��L�;��• 65%��=MFL45%��H��2+�=#$�2+�=3�K��A@O→ZQ\VR�0

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• hs-cTnTK� →-)K"(_ECG_�1IN�*�S^T]Y

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hs-TnT�PMI ���

Type ���

����

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PMI& �

PMI!• ��7���$�hs-cTnT&�"*&14ng/L��&��4Δhs-cTnT5

• ��(ECG�' �%�,#

• 14ng/L'���&9903.2/-1

• 2�&���%)+���

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PMIG�26���PMI7• 1���CE8PMI61���PMI7• �-%3*�3'��EDG�+��G$�FI@B�:.;<L>PMI6Spontaneous AMI7• PMIG9?3<JF�G��M1A�>=HG• 4,-% 3�>EST-T G�!3�)PQONG�!3#�Q�G�!3"��G�&0�3CAGFIK��(/�G��5

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Procedures

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������������������ �������

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JTG-

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RCRI (Revised Cardiac Risk Index)

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� �������European Society of Cardiology, European Society of Anesthesiology

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• ������350μL4�+'-#2���� !���• NSTEMI�����TnT�247��hs-TnT�71���"

hs-TnT���� �����"

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%,+�

• PMI6!�795%CIMAgrsti and Coull6��N• :DHKE9GL�&5J<HK;� 42PMI5�$���6"/8

• �-���4�.-����8+�• Cox��B>LAF@I42PMI536=C?9D6*�HR8,#

• *��72�12nonelective surgery2RCRI2�0�6����M�) 2(��2'�N

• SPSS222R 3.3

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����

• ��041342*��• ���+hs-cTnT �����!&�.����PMI5Δhs-cTnT6�+2�2'��

• -(-(�. ��)���(����0#/$/��*��".%,

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���2�&

• � ��• hs-cTnT2��)-&6��/%����!8�"

• #��0;:<=�/POD21hs-cTnT' �(7-&6�!23>%$�+5;:<

=PMI2*4119���1���10,*��8�+5>%.30����8���

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hs-cTnT�����

• Loess fuction.����/• Δhs-cTnT,��7 ��max hs-cTnT��30 �����������%*#$

• ���hs-cTnT��Δhs-cTnT�4")-%�!%(+& '-����

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Results

• �����2018��2546���

• PMI�397��16%95%CI 14-17%

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$PMI #���"�������RCRI�������"�����

$������ 13%%95%CI 12-15&�ICU!������ 19%%15-23%&�2 ������ 56%%95%CI 46-65&

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ESC/ESA��PMI����lowest�9%�highest�25%

Page 51: 180529 非心臓手術後のPMIjikeimasuika.jp/icu_st/180529.pdfStrengths and Limitations 8Strengths9 • *$FTR[^V]SX\SZYN&J,OB>D •PMIF2-@L# N =F+ • •) Ghs-cTnTG K :PMID %4

(325�)82%* $����(����%&�#$24�)6%*(���)ST-T���T*$60�)24%*)ECG� ��&�244�#�*

( spontaneous AMI"��!����'������#$117�)29%*

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PMI!��

���� 352�)86%�95%CI 82-89%*

����� 55�)14%�95%CI 10-18%*• 40�����'"&#%($!������

• �����9%)95%CI 6-12%*• ICU � ���16%)95%CI 9-27%*• ICU 2������38%)95%CI 26-51%*

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Page 54: 180529 非心臓手術後のPMIjikeimasuika.jp/icu_st/180529.pdfStrengths and Limitations 8Strengths9 • *$FTR[^V]SX\SZYN&J,OB>D •PMIF2-@L# N =F+ • •) Ghs-cTnTG K :PMID %4

��

���

������

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PMI���• 30� ������99.9%�1� �������99.6%

�30���� 56��2.8%�95%CI 2.1-3.6%�• 23��41%�95%CI 29-54%������33��59%�95%CI 46-71%������

�1���� 224��11.2%�95%CI 9.8-12.7%�• 71��32%�95%CI 26-38%������153��68%�95%CI 62-74%������

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30����

�PMI��������285��28��9.8% 95%CI 6.8-14.0%��No PMI��1733��28��1.6% 95%CI 1.1-2.4%��P<0.001�

����� PMI��285��14��4.9% 95%CI 2.8-8.2%��PMI����1733��9��0.5% 95%CI 0.3-1.0%�

PMI

no PMI

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1������PMI����� ��285��64�

�22.5%�95%CI 17.9-27.8%��No PMI��1733��160��9.3%�95%CI 8.0-10.8%��P<0.001�

�����PMI��285��26��9.1%�95%CI 6.2-13.2%��No PMI��1733��45��2.6%�95%CI 1.9-3.5%�

PMI

no PMI

Page 58: 180529 非心臓手術後のPMIjikeimasuika.jp/icu_st/180529.pdfStrengths and Limitations 8Strengths9 • *$FTR[^V]SX\SZYN&J,OB>D •PMIF2-@L# N =F+ • •) Ghs-cTnTG K :PMID %4

PMI30�����HR�2.795%CI 1.5-4.8�P=0.001�

1����HR�1.695%CI 1.2-2.2�P=0.003�

Page 59: 180529 非心臓手術後のPMIjikeimasuika.jp/icu_st/180529.pdfStrengths and Limitations 8Strengths9 • *$FTR[^V]SX\SZYN&J,OB>D •PMIF2-@L# N =F+ • •) Ghs-cTnTG K :PMID %4

PMI#No AMI$�%���AMI�������

!1����22.1%#95%CI 17.6-27.5%$vs29.1%#95%CI 21.4-38.1%$P=0.47

!30����10.4%#95%CI 6.7-15.7%$vs8.7%#95%CI 4.2-16.7%$P&0.684

hs-TnT��� ��'����� "�"

��

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30����

����PMI vs ���PMI�15/245�6.1%�95%CI 3.6-10.0%�vs13/40�32.5%�95%CI 19.8-48.4%�

����PMI �60%���������PMI �39%����

���PMI

���PMI

no PMI

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1����

����PMI vs ���PMI�49/245�20%�95%CI 15-26%�vs15/40�38%�95%CI 24-53%�

����PMI �43%���������PMI ��33%����

���PMI

���PMI

no PMI

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����

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����

• ����� � �����2�hs-cTnT���!��� n=1829!

• 30���������HR�2.8 95%CI1.6-5.2!

• later PMI censoring analysis• 30�������HR�3.2 95%CI 1.8-

5.8!�

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hs-cTnT�30���

�1261��51%������hs-cTnT>=14 ng/L�PMI�� ���80%����hs-cTnT>=14 ng/L

� 1936��76%���hs-cTnT������������3�IQR 1-8��������1626��64%��hs-cTnT>=14

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hs-cTnT�30���

�Δ5���68%��������������Max10���25%��������������Δ�30�����Δ5��� �������

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hs-cTnT����

���������PMI������� �������� ����14������������

↑↑

→↑ ↑→

→→

↑↑

→↑

↑→

→→

Page 67: 180529 非心臓手術後のPMIjikeimasuika.jp/icu_st/180529.pdfStrengths and Limitations 8Strengths9 • *$FTR[^V]SX\SZYN&J,OB>D •PMIF2-@L# N =F+ • •) Ghs-cTnTG K :PMID %4

Discussion

+(�"�%�@�$� @MKH@*2�!@PMI@)�A�2

, PMI@#��AAMI=A�56�>F-PMI�!APMI>8@�?�B;130����A6�.(��PMI<A7E?���611/3A30���?��9F

/%�3E@����' +PMI<��4�6>F0��IOJNL<DPMI�!@10%?83CAG4&CEG:

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���� �#����#.+*#����#PMI#�$��

• PMI$397�/16%0• VISION $17.9%• �����PMI#���cTn#(-,)#��"%&�$�!'

• VISION#��$45��� �.+*#������

Page 69: 180529 非心臓手術後のPMIjikeimasuika.jp/icu_st/180529.pdfStrengths and Limitations 8Strengths9 • *$FTR[^V]SX\SZYN&J,OB>D •PMIF2-@L# N =F+ • •) Ghs-cTnTG K :PMID %4

�PMI*���+AMI'+����(.

• 6%*�"���1��#• 18%"��� �("• 29%"�hs-cTnT*�)AMI*��)��(�1$!#

• -"429<5;36:387�( /,��!/&�$%0�

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Discussion+(�"�%�@�$� @MKH@*2�!@PMI@)�A�2

, PMI@#��AAMI=A�56�>F-PMI�!APMI>8@�?�B;130����A6�.(��PMI<A7E?���611/3A30���?��9F

/%�3E@����' +PMI<��4�6>F0��IOJNL<DPMI�!@10%?83CAG4&CEG:

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����)&������+PMI"�� �$*

• PMI"'��&hs-cTnT&����!(�� !�!(��� �

• hs-cTnT"���+*����&�#���'��

• Δhs-cTnT�max hs-TnT#(%���&��%��

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.���JZKYO9APMI�">10%=62CAG3(@CE7

• AMI:PMI9?/�����<WHPNVB�)<TQ\LWZO3�<D

• AMI?SX\I>�!3�0• PMI>�9?/ �*�?/�%�['%[,#<;>+&� >UMRXZM

• PMI9A���?-4/�$��>��G�5D8F1

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Strengths and Limitations8Strengths9• ��*$FTR[^V]SX\SZYN&J,OB>D• PMIF2-@L# N��=F+�• ���• )�Ghs-cTnTG�K�:PMID���%4�N�• 0�1GWQ\^PUX• �.!<6:_30�IC799.9%`

8Limitations9• PMIG'���<E:• POD2�3G�#��GPMIH��C=E:_hs-cTnTNPOD17

POD27MID"M?:D=7GJF��`• PMI<� �;5� �;(��_CAGN?AGH�/`

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Conclusion

• PMI;(�!�#9-1A�8���• PMICLHU[NYIPXITS6��604• PMI;����Z&���9..BA• PMI\AMI��82]7PMI\AMI��+@]:��;+=@B?8,

• ���9;*PMI:OEULH� C�3A4>:��8LHU[NYIPXITS/�$

• "�DFMGS*��DFMGS9'3AWLRYLPXMJ[V7�<5,4���8K[QETYL: )C�%3ARCT/�$

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Page 76: 180529 非心臓手術後のPMIjikeimasuika.jp/icu_st/180529.pdfStrengths and Limitations 8Strengths9 • *$FTR[^V]SX\SZYN&J,OB>D •PMIF2-@L# N =F+ • •) Ghs-cTnTG K :PMID %4

Editorial%

• ���-2�1$� �#&1000�3/)�"��1��

• PMI2�(��;30����-2�3�1HR&1 ��-2�1.6�1HR

• �(���;��26%&!"��218%&MI1�8�,*,1229%

• ���-4�(��;PMI9AMI�0*:.PMI9AMI�'6:1��2�75+

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Editorial'

• ��9?:>;%$C86%+�� (30����56.1%A)160%+�"� B

• .*.�� PMI4���.*��9?:>;,7/(29%.*!���4��,7/

• ,6-62��C&� �#3��.026�(12�5<=@84��(9�5�����(Cohen MC, 1998)

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• hs-TnT�����%51%����!��• ��������PMI��"�������# ���� �

• �����→16%��PMI�• PMI��20$������������• hs-TnT����"�����&

Editorial�

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• PMI>:0+=A?CFBD@) �• ����5����>.=67!�• PMI646"�5���6��.=(G• ��6hs-TnT)��-1&=�>4'.=(G• ��6CA?E ���%�#E��#2�<(5.=8*�79/9/%

• hs-TnT6A?CFBD@2����.=,36);&(RCT �

Editorial$

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• VISION'+���'18%����'+;4>85��'16%�

• VISION'+� 14������'+2���)��!014��*��

• ��%1(� <@:6B?"�1!• ���*<@:6B?)�.�-2398=A:/��6A7?:,*#&!$)

Editorial�

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POISE VISION 2014 VISION 2017 �)+

�8 2002�o2007� 2007�o2011� 2008�o2013� 2014�o2015��5 190�5?23\� 12�5?8\� 23�5?13\� �5

c`Zj ��E=<> ��E_gld ��E_gld ��E_gld

�6. "45���?�/*�&�Pia]@W

45��� 45���65���?RHQ45���K�&�NM��@W

�6.� 8,351� 15,065� 21,842� 2,018�

!�:(2�TnTRHQ

CKMB 2�TnT 2�hs-TnT 2�2�hs-TnT

PMIP�-�,eZ[hl\lP��L'$k�31J�

�,01OUX2�TnTP��mMINSn

�,01OUX2�hs-TnTP��mMINSn

2�CVPhs-TnTP��

PMIP;� 5.0% 8.0% 17.9% 16%BI01'$@W 34.7% 15.8% 6.9% 18%

PMIP30� �% 11.6% 9.8%3.0%?9.1%?

29.6%m\bd[fFLn

8.9%

#4HRD10�DXLPMIO1.31�NWTGA

MINSP �%�!Pa_Yij^

MINSLeGFRP97

1� �%S

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��

��

���+���#� ��,MI(-�*1/!%

Ischemic signs or symptomsECG/echocardiographyBiomarkers(CM-MB, H-FABP,BNP, cTnT)RCRI/METz

�����23 *)<<

PMI,�-� 99

���'-

���47658T:hs-cTnT;

PMI,�-.-0�"&$9

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��

���+��+�#)"

�hsTnT*�$&.���)(---/ � *�%,�

• type1'type2+��• PMI+��!����+��.���PMI+type2'����PMI/

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��!PMI

• ����(070/5#"&����294.38691%� ��,

• 294.38691!&����(�����*�-�� ,�

• ��%��$)+�PMI%��$����,�'

“Anaesthetics as cardioprotectants: translatability and mechanism”, C Kikuchi BJP 2014 : 172(8) ; 2051-61

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