成人手术患者术前尿钠肽浓度的预测价值：系统回顾与荟萃分析

背景一些研究对术前B型尿钠肽（natriuretic peptides，NPs）用于预测术后死亡率进行了评估，然而，每项研究中死亡例数较少，致使研究效能较差。我们对涉及术前NP水平预测心脏和非心脏手术后死亡的研究进行了系统回顾和荟萃分析。方法我们用“尿钠肽”、“手术或外科手术”检索MEDLINE和EMBASE，与诊断和预测的词有效组合。两名研究人员独立评价研究的入选资格并提取数据。终点为所有≥6个月和≤90天引起死亡的研究。我们使用双变量模型获得预测的精确度和其异质性，用Bayesian Markov chain Monte Carlo法计算混合的阳性预测值（positive predicti vevalue，PPV）和阴性预测值（negative predictive value，NPV）。结果回顾的1558篇文献中，23项研究满足入选标准。心脏手术后，NP对≥6个月死亡的诊断比值比为4．11（95％可信区间，2．22—7．60），PPV为0．17（95％Bayesian可信区间，0．07—0．36），NPV为0．96（0．90—0．98）。非心脏手术后，NP对≥6个月死亡的诊断比值比为4．97（3．06—8．07），相应的PPV为0．24（0．14—0．38），NPV为0．94（0．88—0．97），结果与≤90天死亡的预测值相似。结论术前NP浓度与心脏和非心脏手术后的死亡率相关。NP在两类手术中的NPV均较高，表明术前NP浓度可能有助于术前风险评估分层。

BACKGROUND： Several studies have evaluated preoperative B-type natriuretic peptides （NPs） for predicting mortality after surgery; however, the number of deaths in each study was small, limiting the power of these studies. We conducted a systematic review and meta-analysis of studies addressing preoperative NP levels to predict mortality after cardiac and noncardiac surgery. METHODS： We searched MEDLINE and EMBASE using the terms ＂natriuretic peptides,＂ ＂surgery or surgical procedures,＂ and a validated combination of prognostic and diagnostic terms. Two investigators independently assessed studies for eligibility and extracted data. The end points were all-cause mortality at 〉16 months and at ≤〈90 days. We used a bivariate model to derive measures of prognostic accuracy and their heterogeneity. We calculated the pooled positive predictive value （PPV） and negative predictive value （NPV） by Bayesian Markov chain Monte Carlo methods. RESULTS： Of the 1558 retrieved articles, 23 studies satisfied the predefined eligibility criteria. After cardiac surgery, the diagnostic odds ratio of NP was 4. 11 （95% confidence interval, 2.22 - 7.60） for≥6-month mortality, the PPV 0.17 （95% Bayesian confidence interval, 0.07 -0.36）, and the NPV 0.96 （0.90 -0.98）. After noncardiac surgery, the diagnostic odds ratio of NP was 4.97 （3.06 -8.07） for ≥6-month mortality. The corresponding PPV was 0.24 （0. 14 - 0. 38） and the NPV 0.94 （0. 88 -0.97）. Results were similar for ≤90-day mortality. CONCLUSIONS： Preoperative NP concentrations were associated with mortality after cardiac and noncardiac surgery. NP had high NPVs for both types of surgery suggesting that preoperative NP concentrations may be helpful in preoperative risk stratification.