180529 非心臓手術後のPMIjikeimasuika.jp/icu_st/180529.pdfStrengths and Limitations...
Transcript of 180529 非心臓手術後のPMIjikeimasuika.jp/icu_st/180529.pdfStrengths and Limitations...
2018.5.29���2�� �� ��
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• ������• Editorial
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• ���
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• MI�����
• PMI���������
• MINS�Myocardial injury after noncardiacsurgery
• TnT�Troponin T
• hs-TnT�High sensitivity Troponin T
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Circulation. 2012;126:2020-20352015/04/07 ICU�����2�1� :
PMI0���
• PMI5�!�?�3%���!@3('.��,6��#
• PMI : �!�/4��<9:=>;>4��• "��5&���4"��3�-6• PMI/5&��214��&�$���8�72'+0)�'
• �!�3(*6��� 2��
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PMIPeriopera(ve myocaridial infarc(on
2017 ���M&M��� �
PMI(��
• ��3�*&'7�#��
• ��)150�� ��)350��
1Anesthesiology 2014;120:564-782• ��BNP)��/!.����
1Anesthesiology 2013;119:270-832• RCRI(���)��%
1Ann Intern Med 2010;152:26-352• CKMB)���#�+
• TnT)�� ����'��1��2
• hs-TnT)�� ����',-��$"1��2
PMI��
2 T 3 /
12017 ��M&M �������
Type1 Type2
PMI���
CMAJ 2005 ; 173(6) : 627-34
PMI1�!
• PMI165%2Type2-%:98
• ��5���$����/.,2$type1-type2;�*81' )%
• Type21PMI2�(1?<=>A067supply/demand ischemia0/8+4��'
• ��@����2$Type213&'Type1673��%
• Type22"#$��$� ��'�%$���,ST��'/%�
Cardiovasc Diagn Ther 2017 ; 7(4) : 348-58Journal of the American College of Cardiology 2014 ; 63(20) : 2079-2087
Type2 MI����
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PSVT
The American Journal of Medicine 2013 ; 126(9) : 789-97
������ !2014"
������������ ���������������� (2014 ����).
PMI��������
• POISE trial �2008�
• VISION study �2014�
• VISION study �2017�
Characteristics and Short-Term Prognosis of PerioperativeMyocardial Infarction in Patients Undergoing Noncardiac Surgery
Annals of Internal Medicine 2011 ; 154 : 523-528
POISE trial
• . �/+�$�%7�16�#3PMI5��4!�� 7�'
• .>=9C/��0RCTFβ blocker or placeboG• .��/425@9;AE<E7% 3�*�• .�)/190 �( 23 D-45���58351�• .8:?<B/PMI5,�-30����• .PMI5"/@9;AE<E5��412��5MI�&
POISE trial• 415 � (5.0%) �PMI 65%�����• ST���31.3% ��T��21.7% ST���10.6%��
Annals of Internal Medicine 2011 ; 154 : 523-528
POISE trial• PMI��$30����%11.6%�no PMI��#%2.2%*p<0.001+
• �� PMI%CPA����! ���� PMI%����! �
• PMI MI��$��#��)'"���($PMI ����$&$PMI TnT��$&
Annals of Internal Medicine 2011 ; 154 : 523-528
POISE trial• �� HR10�����PMI �����31%��
Annals of Internal Medicine 2011 ; 154 : 523-528
A Large, International, Prospective Cohort Study Establishing Diagnostic Criteria, Characteristics, Predictors, and 30-day Outcomes
Anesthesiology 2014 ; 120 : 564-78
• +��,MINS0#��*��*����*����3�"
• +:95A,(��-8=B;$)• +��,;@><ATCTnTD3!�3�'��*
TnT>=0.04 .ischemic features3%�
• + &,45���015,065�
• +46;7?,30����CprimaryD
• +MINS0� , peak TnT>=0.03 ng/mLCmyocardial ischemia/12D
VISION study (2014)
VISION study (2014)
• MINS 1,194� 8.0%�
• MINS30���������(adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08)
Anesthesiology 2014 ; 120 : 564-78
VISION study (2014)• ��������eGFR������!�� ��• eGFR↓�MINS��!$#"↑• ��eGFR�30 �����������������%P=0.48&
Anesthesiology 2014 ; 120 : 564-78
VISION study (2014)
MINS�30������������
75�� 1 ST�or������ 2 �����ECG� 1
Anesthesiology 2014 ; 120 : 564-78
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
VISION study (2017)
• 5$#62��LRPMSTUhs-TnTV<30���">/�B�*3MINS>,� !>�*
• 5KIDS6��8�0HOTL%&• 5��6hsTnTB)�6~12�.�3POD1~3= �440.4%?)�=@hsTnT7 �
• 5�-623�+13G�31�(�)B9;45���>21,842�>�'
• 5CELGQ6��7�:Ahs-TnT>GJLFN�
VISION study (2017)
• Peak hs-TnT 20-65 ng/L→3.0%• Peak hs-TnT 65-1000 ng/L→9.1%• Peak hs-TnT >=1000 ng/L→29.6%
JAMA. 2017 ; 317(16) : 1642-51
VISION study (2017)
• MINS�17.9%• MINS�Major
bleeding�� ����Af����5��30���������
JAMA. 2017 ; 317(16) : 1642-51
POISE VISION 2014 VISION 2017�2 2002�d2007� 2007�d2011� 2008�d2013��/ 190�/923Q� 12�/98Q� 23�/913Q�
XUO_ �>768 �>T\aY �>T\aY
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PMIG ' �&ZOP]aQaG��D# `�-1C��
�&*+FKM,�TnTG��bMINSc
�&*+FKM,�TnTG��bMINSc
PMIG5� 5.0% 8.0% 17.9%<B*+# :L 34.7% 15.8% 6.9%
PMIG30���! 11.6% 9.8% 3.0%99.1%929.6%bQWYP[?Dc
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• PMIIE3��6GMJKNPLP• PMI?��
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Introduction
• PMI)�����'� .���$!"��• MI$�*���&%��'�!�• ECG&%+�'�!�• 03214T5TnT6)��• high-sensitivity cardiac troponin (hs-cTnT))�(����/,-,� �#�.7
Aim
• �����*�")PMI.+/-,��• ���&PMI screening program*��• ��0� 'hs-cTnT'��• screening program#PMI*%'����#!) 3
• PMI$� 130�����1���2$'��*�()
Methods>�9?• [`W]��,;H<�4�5P�CO�0• 5�24!:��L�;��• 65%��=MFL45%��H��2+�=#$�2+�=3�K��A@O→ZQ\VR�0
>XUQ^?• �8=� B7�./>�&?• PMI screening programP2014�a2015�J��• hs-cTnTL�5K30!:�=POD1=POD2=EDG�6!J'�
• hs-cTnTK� →-)K"(_ECG_�1IN�*�S^T]Y
hs-TnT�PMI ���
Type ���
����
PMI& �
PMI!• ��7���$�hs-cTnT&�"*&14ng/L��&��4Δhs-cTnT5
• ��(ECG�' �%�,#
• 14ng/L'���&9903.2/-1
• 2�&���%)+���
Δ6��&����
PMIG�26���PMI7• 1���CE8PMI61���PMI7• �-%3*�3'��EDG�+��G$�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
Procedures
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• Primary end point 30����• Secondary end point 1���• ��.!539<3>-01��� +���� -�
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• 45���!��24����-��!��&6;>7=!��14���-MI/)'.����!hs-cTnT&1�)%�(2*$,$
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• .�DQI;RNTK2=-• RCRI:��*#• �(9�'$PFE:European Society of Cardiology,
European Society of Anesthesiology8<?�/
• �� �:0�'!0&�0% �!0%�0(�4A�@-
• LCSTBHM:01��8OTQ2.+2��9��",71LCSTBHM2=�35�:��9�)9��7�6�>
RCRI (Revised Cardiac Risk Index)
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_-�+?�(Cr > 2.0 mg/dL)
@�0�5NFHU��"�O7�L'�N=IUXW[\W^(2014�)
� �������European Society of Cardiology, European Society of Anesthesiology
�� ����������������
hs-cTnT���
• Modular Analytics E170, Cobas e602 (Roche Diagnostic)��
• 5 ng/L������10%���13 ng/L�����99�!� ����14 ng/L
• hs-cTnT� �30�����#83"�1����94%�3���$���
hs-cTnT����• �����C1 region�TnT��.$&�/*%12)0���hs-TnT��,(�IgG��
• ������350μL4�+'-#2���� !���• NSTEMI�����TnT�247��hs-TnT�71���"
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%,+�
• PMI6!�795%CIMAgrsti and Coull6��N• :DHKE9GL�&5J<HK;� 42PMI5�$���6"/8
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• *��72�12nonelective surgery2RCRI2�0�6����M�) 2(��2'�N
• SPSS222R 3.3
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• -(-(�. ��)���(����0#/$/��*��".%,
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• #��0;:<=�/POD21hs-cTnT' �(7-&6�!23>%$�+5;:<
=PMI2*4119���1���10,*��8�+5>%.30����8���
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• ���hs-cTnT��Δhs-cTnT�4")-%�!%(+& '-����
Results
• �����2018��2546���
• PMI�397��16%95%CI 14-17%
$PMI #���"�������RCRI�������"�����
$������ 13%%95%CI 12-15&�ICU!������ 19%%15-23%&�2 ������ 56%%95%CI 46-65&
ESC/ESA��PMI����lowest�9%�highest�25%
(325�)82%* $����(����%&�#$24�)6%*(���)ST-T���T*$60�)24%*)ECG� ��&�244�#�*
( spontaneous AMI"��!����'������#$117�)29%*
PMI!��
���� 352�)86%�95%CI 82-89%*
����� 55�)14%�95%CI 10-18%*• 40�����'"&#%($!������
• �����9%)95%CI 6-12%*• ICU � ���16%)95%CI 9-27%*• ICU 2������38%)95%CI 26-51%*
��
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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%������
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
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
PMI30�����HR�2.795%CI 1.5-4.8�P=0.001�
1����HR�1.695%CI 1.2-2.2�P=0.003�
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%$P&0.684
hs-TnT��� ��'����� "�"
��
30����
����PMI vs ���PMI�15/245�6.1%�95%CI 3.6-10.0%�vs13/40�32.5%�95%CI 19.8-48.4%�
����PMI �60%���������PMI �39%����
���PMI
���PMI
no PMI
1����
����PMI vs ���PMI�49/245�20%�95%CI 15-26%�vs15/40�38%�95%CI 24-53%�
����PMI �43%���������PMI ��33%����
���PMI
���PMI
no PMI
����
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• ����� � �����2�hs-cTnT���!��� n=1829!
• 30���������HR�2.8 95%CI1.6-5.2!
• later PMI censoring analysis• 30�������HR�3.2 95%CI 1.8-
5.8!�
hs-cTnT�30���
�1261��51%������hs-cTnT>=14 ng/L�PMI�� ���80%����hs-cTnT>=14 ng/L
� 1936��76%���hs-cTnT������������3�IQR 1-8��������1626��64%��hs-cTnT>=14
hs-cTnT�30���
�Δ5���68%��������������Max10���25%��������������Δ�30�����Δ5��� �������
hs-cTnT����
���������PMI������� �������� ����14������������
↑↑
→↑ ↑→
→→
↑↑
→↑
↑→
→→
Discussion
+(�"�%�@�$� @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:
���� �#����#.+*#����#PMI#�$��
• PMI$397�/16%0• VISION $17.9%• �����PMI#���cTn#(-,)#��"%&�$�!'
• VISION#��$45��� �.+*#������
�PMI*���+AMI'+����(.
• 6%*�"���1��#• 18%"��� �("• 29%"�hs-cTnT*�)AMI*��)��(�1$!#
• -"429<5;36:387�( /,��!/&�$%0�
Discussion+(�"�%�@�$� @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:
����)&������+PMI"�� �$*
• PMI"'��&hs-cTnT&����!(�� !�!(��� �
• hs-cTnT"���+*����&�#���'��
• Δhs-cTnT�max hs-TnT#(%���&��%��
.���JZKYO9APMI�">10%=62CAG3(@CE7
• AMI:PMI9?/�����<WHPNVB�)<TQ\LWZO3�<D
• AMI?SX\I>�!3�0• PMI>�9?/ �*�?/�%�['%[,#<;>+&� >UMRXZM
• PMI9A���?-4/�$��>��G�5D8F1
Strengths and Limitations8Strengths9• ��*$FTR[^V]SX\SZYN&J,OB>D• PMIF2-@L# N��=F+�• ���• )�Ghs-cTnTG�K�:PMID���%4�N�• 0�1GWQ\^PUX• �.!<6:_30�IC799.9%`
8Limitations9• PMIG'���<E:• POD2�3G�#��GPMIH��C=E:_hs-cTnTNPOD17
POD27MID"M?:D=7GJF��`• PMI<� �;5� �;(��_CAGN?AGH�/`
Conclusion
• PMI;(�!�#9-1A�8���• PMICLHU[NYIPXITS6��604• PMI;����Z&���9..BA• PMI\AMI��82]7PMI\AMI��+@]:��;+=@B?8,
• ���9;*PMI:OEULH� C�3A4>:��8LHU[NYIPXITS/�$
• "�DFMGS*��DFMGS9'3AWLRYLPXMJ[V7�<5,4���8K[QETYL: )C�%3ARCT/�$
Editorial%
• ���-2�1$� �#&1000�3/)�"��1��
• PMI2�(��;30����-2�3�1HR&1 ��-2�1.6�1HR
• �(���;��26%&!"��218%&MI1�8�,*,1229%
• ���-4�(��;PMI9AMI�0*:.PMI9AMI�'6:1��2�75+
Editorial'
• ��9?:>;%$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)
• hs-TnT�����%51%����!��• ��������PMI��"�������# ���� �
• �����→16%��PMI�• PMI��20$������������• hs-TnT����"�����&
Editorial�
• PMI>:0+=A?CFBD@) �• ����5����>.=67!�• PMI646"�5���6��.=(G• ��6hs-TnT)��-1&=�>4'.=(G• ��6CA?E ���%�#E��#2�<(5.=8*�79/9/%
• hs-TnT6A?CFBD@2����.=,36);&(RCT �
Editorial$
• VISION'+���'18%����'+;4>85��'16%�
• VISION'+� 14������'+2���)��!014��*��
• ��%1(� <@:6B?"�1!• ���*<@:6B?)�.�-2398=A:/��6A7?:,*#&!$)
Editorial�
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29.6%m\bd[fFLn
8.9%
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• 294.38691!&����(�����*�-�� ,�
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