为远期获益密切监测开腹行腹主动脉手术患者的心肌肌钙蛋白具有成本效益：一种决策分析模型  

作　　者：Srinivas Mantha, MD Joseph Foss, MD John E. Ellis, MD Michael F. Roizen MD 桂波(译) 李静(译) 

机构地区：[1]Department of Anesthesiology, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India [2]Department of Anesthesiology, The Cleveland Clinic Foundation, Cleveland, Ohio and [3]Department of Anesthesiology and Critical Care, The University of Chicago, Chicago, Illinois [4]不详

出　　处：《麻醉与镇痛》2009年第2期6-17,共12页Anesthesia & Analgesia

摘　　要：背景控制血管手术后心脏不良事件的策略在不断改进。早期发现和处理心肌缺血是提高手术后生存率的关键因素。心肌肌钙蛋白Ⅰ（cTnⅠ）的筛查是监测手术后心肌缺血性损伤的有效方法，并具有长期的预后价值。方法我们设计了一个马尔柯夫决策分析模型来评估手术后第0、1、2、3天常规监测cTnⅠ的成本效益，其目的还在于将手术后cTnⅠ〉1．5ng/ml的患者移入重症监护病房观察5天，严格控制目标心率（60～65次／分），并进行严密监测和冠状动脉监护。根据已发表的文献所输入的主要变量如下：心肌梗死的概率0．049；监测cTnⅠ的成本为357美元；干预的成本和效率分别为13145美元和0．55。以寿命为时间轴，目标人群是平均年龄为65岁的行择期开腹腹主动脉手术的患者。此研究分析的费用来自第3方。结果相对于没有监测cTnⅠ的对照组，每个生命质量调整年用于监测cTnⅠ增加的成本效益为12641美元。单因素方差分析显示心肌梗死的可能性和干预的效能会影响成本效益。采用二次合并蒙特卡罗模拟分析行多因素敏感性分析显示，在每个生命质量调整年用低于50000美元的费用监测cTnⅠ，其获益率可达到90．75％。结论对于择期行开腹腹主动脉手术的住院患者，加强cTnⅠ监测并早期积极地使用β-受体阻滞剂会带来成本效益。BACKGROUND： Strategies to limit adverse cardiac events after vascular surgery continue to evolve. Early recognition and treatment of myocardial ischemia may be a key to improving postoperative survival rates. Cardiac troponin Ⅰ （cTnⅠ） screening is an effective means of surveillance for postoperative myocardial ischemic injury and has long-term prognostic value. METHODS： We designed a Markov-based decision analysis model to determine the cost-effectiveness of routine surveillance with cTnⅠ on postoperative Days 0, 1,2, and 3, with an aim to institute tight heart rate control （60 - 65 bpm） with close monitoring and coronary care in the intensive care unit for 5 days in patients with cTnⅠ 1.5 〉 ng/ml. The key input variables obtained from published literature were as follows： probability of myocardial infarction, 0.049; cost of cTnⅠ surveillance, $357; cost and efficacy of interventions, $13 145 and 0. 55, respectively. The time horizon was lifetime and the target population being individuals aged 65 yr （median） undergoing elective open abdominal aortic surgery. The perspective for analysis was third-party payer. RESULTS： The incremental cost-effectiveness ratio for cTnⅠ surveillance was $12 641 per quality-adjusted life year compared with standard care without cTnⅠ surveillance. During one-way sensitivity analysis, probability of myocardial infarction and efficacy of interventions were found to influence the cost-effectiveness. Multivariate sensitivity analysis with second-order Monte Carlo simulation revealed that cTnⅠ surveillance was favored in 90. 75% of simulations at a commonly used threshold of $50 000 per quality-adjusted life year. CONCLUSIONS： In patients presenting for elective open abdominal aortic surgery, intensive surveiUance with cTnⅠ and early institution of aggressive β-blockade is costeffective.

关 键 词：心肌肌钙蛋白Ⅰ 腹主动脉手术 常规监测 成本效益 决策分析 开腹 模型 心肌缺血性损伤 

分 类 号：R542.22[医药卫生—心血管疾病] R318.01[医药卫生—内科学]