Abstract
目的
探讨术前心内科会诊是否可以降低非心脏手术患者主要不良心脏事件（MACE）的发生率。
方法
研究共纳入7019例65岁及以上非心脏手术患者，患者均存在心电图（ECG）异常。主要结局指标为术后30 d内MACE的发生率。按7∶3比例将人群分为开发队列和验证队列，并根据ECG异常风险分为高危组和低危组。各亚组建立了MACE预测模型，采用受试者工作特征曲线（ROC曲线）分析其预测效能，并通过决策曲线分析（DCA）评估术前心内科会诊的价值。
结果
开发队列共有4914例患者，3010例为低风险的异常心电图，其中61例发生MACE（2.0%），1904例为高风险的异常心电图，其中59例发生MACE（3.1%）。在MACE的预测模型中，低风险组包含6个危险因素（AUC=0.772），而高风险组包含5个危险因素（AUC=0.769）。对于低风险的异常心电图患者，接受心内科会诊并未显示出显著的益处（预测发生主要不良心脏事件的风险阈值为0.02）。高风险异常心电图组和合并某些危险因素的低风险异常心电图组中，接受心内科会诊显示出显著的获益（预测发生主要不良心脏事件的风险阈值分别为0.3和0.229）。
结论
高危异常ECG和有特定危险因素的低危异常ECG患者行心内科会诊可降低术后MACE发生率；而单纯低危异常ECG患者术前心内科会诊并未见明显获益，且未改善MACE的发生率。
Keywords: 异常心电图, 术前心内科会诊, 主要不良心脏事件, 老年患者
Abstract
Objective
To investigate whether preoperative cardiology consultation reduces the incidence of major adverse cardiac events (MACE) in patients undergoing non-cardiac surgeries.
Methods
This cohort study was conducted among 7019 elderly patients (above 65 years) with abnormal ECGs undergoing non-cardiac surgeries. The main outcome was MACE occurrence within 30 days post-surgery. The patients were divided into model development and validation cohorts in a 7:3 ratio, and each cohort was categorized into two subgroups with high-risk and low-risk abnormal ECG. MACE prediction models were constructed for the subgroups, and their predictive power was evaluated using ROC curves; the value of preoperative cardiology consultation for reducing MACE was assessed using decision curve analysis.
Results
Among the 4914 patients in the model development cohort, 61 of the 3010 patients with low-risk abnormal ECGs experienced MACE (2.0%), as compared with 59 out of 1904 patients (3.1%) in the high-risk group. The predictive model for MACE for the low-risk group contained 6 risk factors (AUC=0.772), and that for the high-risk group contained 5 risk factors (AUC=0.769). In patients with low-risk abnormal ECG, undergoing cardiovascular specialist consultation did not show significant benefits (the survival rate for predicting MACE was 0.02). However, in patients with high-risk abnormal ECG and those with low-risk abnormal ECG but having specific risk factors, undergoing cardiovascular specialist consultation showed significant benefits with survival rates for predicting MACE of 0.3 and 0.229, respectively.
Conclusion
For patients with high-risk abnormal ECG and those with low-risk abnormal ECG and specific risk factors, preoperative cardiology consultation may help to reduce the occurrence of MACE following non-cardiac surgeries, but for patients with simple low-risk abnormal ECG cases without risk factors, preoperative cardiology consultation can be omitted, which does not affect the incidence of MACE but can improve medical efficiency.
Keywords: abnormal electrocardiogram, preoperative cardiology consultation, major adverse cardiac events, elderly patients
随着医疗水平的提高，中国人群的平均预期寿命延长，需要接受手术治疗的患者数量不断增加［1］。在非心脏手术患者中，3%~5%的患者在术后1个月内发生重大不良心脏事件（MACE）包括心力衰竭、恶性心律失常、心肌梗死、心搏骤停等［2］。这也是围手术期心血管相关发病率和死亡率的主要原因之一［3］。
术前心电图（ECG）是围手术期评估的重要手段［4］。该检查可在一定程度上反映心脏状态，并提示围手术期是否存在发生不良心脏事件的风险［5， 6］。当患者术前心电图异常时，常规医疗流程常启动心内科会诊评估心脏风险并调整心脏功能。有研究表明，该措施可降低大血管手术中心肌梗死的发生概率［7］。然而，研究表明术前心内科会诊会延长老年股骨骨折患者的手术时间，从而增加死亡率和发病率［8］。也有研究发现，心内科会诊与腹主动脉瘤修补术的重大心脏不良事件（MACE）无关［9］。对于低风险患者，术前心内科会诊也可能导致住院时间延长、费用增加以及术前检查的过度使用［10］。目前，在我国临床实践中，针对术前心电图异常的患者进行心内科会诊已成为常规操作。虽有研究强调对贫血、肝功能异常、心脏疾病等明确危险因素进行术前多学科会诊的重要性［11］。但一个关键且尚未被充分解答的临床问题是：对于所有术前心电图异常的老年患者，这一常规会诊流程是否都能改善其术后预后？现有研究多聚焦于心内科会诊对宽泛手术人群或特定手术类型的影响，其结论不一，且未能专门解答“异常心电图”这一普遍触发会诊的具体指征，在老年患者这一高危群体中的真实价值。针对“异常心电图即启动会诊”这一常规做法，尚缺乏以患者预后为导向的精细化评估。
因此，本研究旨在填补这一空白，聚焦于术前心电图异常的老年非心脏手术患者，评估常规心内科会诊与此类患者术后预后之间的关联。与既往研究相比，本研究并非简单探讨会诊的“有无”效应，而是致力于回答一个更精准的临床决策问题：在老年人群中，哪些或何种类型的异常心电图可能从会诊中真正获益？本研究通过分析心内科会诊与非心脏手术患者心脏不良事件发生率之间的关系，全面评估心内科会诊的价值。我们旨在筛选出术前需进行心内科会诊的患者，并推荐一种更具经济性和实用性的流程。
1. 资料和方法
1.1. 研究设计
本回顾性队列研究经中国人民解放军总医院伦理委员会批准（伦理批号：S2024-642-02），并于2025年4月启动前在ClinicalTrials.gov临床试验注册库完成注册（注册号：NCT06884436，注册日期：2025年3月25日）。研究期间已获得患者及其家属的知情同意。本研究严格遵循《赫尔辛基宣言》及相关规范。
本研究纳入对象为2017年1月~2019年8月在中国人民解放军总医院第一医学中心接受择期手术的患者。纳入标准：年龄≥65岁，接受非心脏手术，，术前存在异常心电图的患者。排除标准：术后30 d内接受过二次手术，拒绝参与研究的患者。
收集患者术前基线数据，包括年龄、性别、体质量指数（BMI）及其他相关数据。同时记录患者术前3个月内出现的各类异常心电图类型，以及是否接受过心内科会诊。此外，采集实验室检查和病史，并详细记录每位患者本次入院接受的具体手术操作。根据心内科医生和麻醉医生的经验，将异常心电图分为低风险和高风险（表1）。随后提取了病历记录中术后30 d内主要心脏不良事件（MACE）。本研究采用盲法设计，负责心电图分组的临床医生对MACE的发生情况并不知情。
表1.
异常心电图分类
Tab.1 Classification of abnormal ECG
| Classification | Contents |
|---|---|
| Low-risk abnormal ECG |
Sinus bradycardia (≥50 beats per minute ) Sinus tachycardia (≤120 beats per minute ) Sinus rhythm with occasional atrial premature beats Sinus rhythm with occasional premature ventricular contractions Sinus rhythm with first-degree atrioventricular block Sinus rhythm with incomplete right bundle branch block Sinus rhythm with localized right bundle branch block Sinus rhythm with complete right bundle branch block Sinus rhythm with left anterior fascicular block Sinus rhythm with left axis deviation Sinus rhythm with right axis deviation Sinus rhythm with low voltage in limb leads Sinus rhythm with early repolarization Sinus rhythm with normal P wave morphology Sinus rhythm with widened P wave morphology Sinus rhythm with abnormal T Sinus irregularity |
| High-risk abnormal ECG |
Sinus bradycardia (≤49 beats per minute ) Sinus tachycardia(≥121 beats per minute ) Sinus rhythm with left ventricular hypertrophy Sinus rhythm with prolonged QTc interval Sinus rhythm with second-degree atrioventricular block Sinus rhythm with third-degree atrioventricular block Sinus rhythm with complete left bundle branch block Sinus rhythm with frequent premature atrial contractions Sinus rhythm with frequent atrial premature beats Sinus rhythm with atrial premature beats in a 2:1 pattern Sinus rhythm with elevated u-wave Sinus rhythm with abnormal Q-waves Sinus rhythm with inverted T waves in leads V4-V6 Sinus rhythm with high voltage T wave Sinus rhythm with ST-T depression Sinus rhythm with ST-T segment elevation Supraventricular tachycardia Ventricular tachycardia Paced rhythm Short pr syndrome Atrial fibrillation Atrial flutter Accelerated A-V junctional escape rhythm Brugada syndrome Pre-excitation syndrome Combination of two low-risk abnormal electrocardiographic findings Combination of two or more high-risk abnormal electrocardiographic findings |
MACE定义为非心脏手术期间或术后30 d内发生的急性心肌梗死（MI）、不稳定型心绞痛、心力衰竭（HF）、新发严重心律失常、非致死性心搏骤停及心脏性死亡的复合事件［12］。通过查阅病历资料确定MACE病例。采用结构化查询语言（一种标准化数据检索语言）提取相关数据要素，包括术后生化检测、心电图（ECG）、冠状动脉造影、术后病程记录及会诊报告，患者可能经历多次MACE。由3位经验丰富的临床医生进行独立并发症评估，任何分歧通过讨论达成共识解决。
MI［13］定义为肌钙蛋白水平升高后继发下降，并伴随以下一项或多项标准：缺血症状、ECG异常Q波、ST段改变或冠状动脉介入治疗（如血管成形术）。心衰的诊断包括新发的呼吸困难或疲劳、体位性呼吸困难、阵发性夜间呼吸困难、颈静脉压升高、肺部啰音、心肌肥大或肺充血［14］。新发严重心律失常通过ECG表现识别，包括心房扑动、心房颤动、室性心动过速、室颤或二度/三度房室传导阻滞。非致死性心搏骤停定义为心脏活动停止或呈现紊乱节律，需实施基础或高级生命支持措施。心脏性死亡定义为任何非明确非心血管原因导致的死亡。
1.2. 统计学分析
本研究的总体人群按照7∶3的比例进行划分，将数据分为开发队列和验证队列。将开发队列进一步分为两个独立亚组：高风险异常心电图组和低风险异常心电图组，分别构建MACE的预测模型。验证队列中的低风险异常心电图数据集和高风险异常心电图数据集用于验证。分类变量以例数（百分比）表示，采用卡方检验进行分析。P<0.05被认为差异具有统计学意义。
采用R软件4.2.1进行单变量和多变量逻辑回归分析，确定高危和低危异常心电图患者发生MACE的危险因素。首先进行单变量分析以评估各变量的统计学显著性，随后对单变量分析中显著的变量进行多变量分析，以确定MACE的预测因子，并建立包含统计学显著预测因子的列线图风险评分，用于预测异常ECG人群的MACE评分。对发生MACE并接受会诊的患者群体进行分析，计算其最低评分。若评分高于此阈值，则建议进行术前心内科会诊。根据预测MACE的评分，依据实际风险概率的四分位数计算低、中、高、超高预测评分的截断值。绘制受试者工作特征（ROC）曲线以评估模型的预测能力，采用Hosmer-Lemeshow检验和校准曲线评估模型的校准能力，并通过不同阈值概率决策曲线（DCA）下的净获益评估列线图风险评分的临床实用性。
2. 结果
2.1. 患者特征
本研究共纳入7019例病例，男性3900例（55.6%），女性3119例（44.4%）；75岁以上患者1353例（19.3%），75岁以下患者5666例（80.7%）。其中低风险心电图异常病例4302例，高风险心电图异常病例2717例。低风险心电图异常患者中发生MACE共86例（2.0%），高风险心电图异常患者中发生MACE 共85例（3.1%）。患者基线特征见表2。在4914例开发队列中，低风险异常心电图病例3010例，其中发生MACE 61例（2.0%）。另有1904例高危异常心电图患者中，59例发生MACE（3.1%，表3）。
表2.
患者基线人口学和临床特征
Tab.2 Baseline demographic and clinical characteristics of the patients with and without MACE
| Characteristic | MACE No. (%) (n=7019) | |
|---|---|---|
| Negative (n=6848) | Positive (n=171) | |
| Cardiology consultation | ||
| No | 2132 (31.1%) | 6 (3.5%) |
| Yes | 4716 (68.9%) | 165 (96.5%) |
| Gender | ||
| Female | 3038 (44.4%) | 81 (47.4%) |
| Male | 3810 (55.6%) | 90 (52.6%) |
| Age (year) | ||
| <75 | 5555 (81.1%) | 111 (64.9%) |
| ≥75 | 1293 (18.9%) | 60 (35.1%) |
| BMI (kg/m2) | ||
| 18-24 | 2898 (42.3%) | 71 (41.5%) |
| <18 | 173 (2.5%) | 4 (2.3%) |
| >24 | 3777 (55.2%) | 96 (56.1%) |
| Comorbidities | ||
| Hypertension | 3390 (49.5%) | 105 (61.4%) |
| Cerebrovascular disease | 547 (8%) | 19 (11.1%) |
| Diabetes | 1768 (25.8%) | 44 (25.7%) |
| Coronary artery disease | 965 (14.1%) | 48 (28.1%) |
| Arrhythmia | 1174 (17.1%) | 51 (29.8%) |
| Valvular heart disease | 39 (0.6%) | 3 (1.8%) |
| Myocardial infarction | 105 (1.5%) | 12 (7%) |
| Congestive heart failure | 18 (0.3%) | 11 (6.4%) |
| Hepatic insufficiency | 363 (5.3%) | 8 (4.7%) |
| Renal insufficiency | 96 (1.4%) | 8 (4.7%) |
| RBC (1012/L) | ||
| 3.5-5.5 | 6290 (91.9%) | 136 (79.5%) |
| >5.5 | 68 (1%) | 1 (0.6%) |
| <3.5 | 490 (7.2%) | 34 (19.9%) |
| PLT (109/L) | ||
| 100-300 | 6008 (87.7%) | 144 (84.2%) |
| <100 | 157 (2.3%) | 0 (0%) |
| >300 | 683 (10%) | 27 (15.8%) |
| HGB (g/L) | ||
| 110-160 | 5906 (86.2%) | 124 (72.5%) |
| >160 | 184 (2.7%) | 6 (3.5%) |
| <110 | 758 (11.1%) | 41 (24%) |
| WBC (109/L) | ||
| 4-10 | 6004 (87.7%) | 147 (86%) |
| <4 | 588 (8.6%) | 8 (4.7%) |
| >10 | 256 (3.7%) | 16 (9.4%) |
| Cr (µmmol/L) | ||
| 44-110 | 6419 (93.7%) | 144 (84.2%) |
| <44 | 116 (1.7%) | 5 (2.9%) |
| >110 | 313 (4.6%) | 22 (12.9%) |
| GLU (mmol/L) | ||
| 3.4-6.1 | 5350 (78.1%) | 126 (73.7%) |
| <3.4 | 32 (0.5%) | 0 (0%) |
| >6.1 | 1466 (21.4%) | 45 (26.3%) |
| APTT (s) | ||
| ≤40 | 5846 (85.4%) | 136 (79.5%) |
| >40 | 1002 (14.6%) | 35 (20.5%) |
| D-dimer (ng/mL) | ||
| ≤0.5 | 4756 (69.5%) | 53 (31%) |
| >0.5 | 2092 (30.5%) | 118 (69%) |
| Abnormal ECG | ||
| Low-risk abnormal ECG | 4216 (61.6%) | 86 (50.3%) |
| High-risk abnormal ECG | 2632 (38.4%) | 85 (49.7%) |
| Type of surgery | ||
| ENT, ophthalamic, oral surgery and minor surgery | 1045 (15.3%) | 11 (6.4%) |
| Hepatobiliary pancreatic splenic surgery | 1390 (20.3%) | 22 (12.9%) |
| Orthopedic surgery | 681 (9.9%) | 13 (7.6%) |
| Pelvic surgery | 885 (12.9%) | 22 (12.9%) |
| Nervous system surgery | 994 (14.5%) | 25 (14.6%) |
| Gastrointestinal surgery | 1116 (16.3%) | 45 (26.3%) |
| Thoracic and vascular surgery | 737 (10.8%) | 33 (19.3%) |
BMI: Body mass index; RBC: Red blood cell; PLT: Platelets; HGB: Hemoglobin; WBC:White blood cell; Cr: Creatinine; GLU: Glucose; APTT: Activated partial thromboplastin time; ECG: Electrocardiogram; ENT: Ear nose and throat.
表3.
开发队列的基线人口学和临床特征
Tab.3 Baseline demographic and clinical characteristics of the patients in the model development cohort
| Characteristic | MACE No. (%) (n=4914) | |
|---|---|---|
| Negative (n=4794) | Positive (n=120) | |
| Gender | ||
| Female | 2135 (44.5%) | 55 (45.8%) |
| Male | 2659 (55.5%) | 65 (54.2%) |
| Age (year) | ||
| <75 | 3858 (80.5%) | 80 (66.7%) |
| ≥75 | 936 (19.5%) | 40 (33.3%) |
| BMI (kg/m2) | ||
| 18-24 | 2019 (42.1%) | 45 (37.5%) |
| <18 | 132 (2.8%) | 3 (2.5%) |
| >24 | 2643 (55.1%) | 72 (60%) |
| Comorbidities | ||
| Hypertension | 2417 (50.4%) | 72 (60%) |
| Cerebrovascular disease | 388 (8.1%) | 11 (9.2%) |
| Diabetes | 1219 (25.4%) | 32 (26.7%) |
| Coronary artery disease | 689 (14.4%) | 34 (28.3%) |
| Arrhythmia | 814 (17%) | 36 (30%) |
| Valvular heart disease | 26 (0.5%) | 3 (2.5%) |
| Myocardial infarction | 78 (1.6%) | 6 (5%) |
| Congestive heart failure | 10 (0.2%) | 4 (3.3%) |
| Hepatic insufficiency | 263 (5.5%) | 7 (5.8%) |
| Renal insufficiency | 66 (1.4%) | 5 (4.2%) |
| RBC (1012/L) | ||
| 3.5-5.5 | 4402 (91.8%) | 97 (80.8%) |
| >5.5 | 48 (1%) | 1 (0.8%) |
| <3.5 | 344 (7.2%) | 22 (18.3%) |
| PLT (109/L) | ||
| 100-300 | 4188 (87.4%) | 103 (85.8%) |
| <100 | 114 (2.4%) | 0 (0%) |
| >300 | 492 (10.3%) | 17 (14.2%) |
| HGB (g/L) | ||
| 110-160 | 4131 (86.2%) | 90 (75%) |
| >160 | 134 (2.8%) | 5 (4.2%) |
| <110 | 529 (11%) | 25 (20.8%) |
| WBC (109/L) | ||
| 4-10 | 4196 (87.5%) | 100 (83.3%) |
| <4 | 417 (8.7%) | 6 (5%) |
| >10 | 181 (3.8%) | 14 (11.7%) |
| Cr (µmmol/L) | ||
| 44-110 | 4506 (94%) | 101 (84.2%) |
| <44 | 70 (1.5%) | 4 (3.3%) |
| >110 | 218 (4.5%) | 15 (12.5%) |
| GLU (mmol/L) | ||
| 3.4-6.1 | 3760 (78.4%) | 85 (70.8%) |
| <3.4 | 26 (0.5%) | 0 (0%) |
| >6.1 | 1008 (21%) | 35 (29.2%) |
| APTT (s) | ||
| ≤40 | 4111 (85.8%) | 100 (83.3%) |
| >40 | 683 (14.2%) | 20 (16.7%) |
| D-dimer (ng/mL) | ||
| ≤0.5 | 3330 (69.5%) | 38 (31.7%) |
| >0.5 | 1464 (30.5%) | 82 (68.3%) |
| Abnormal ECG | ||
| Low-risk abnormal ECG | 2949 (61.5%) | 61 (50.8%) |
| High-risk abnormal ECG | 1845 (38.5%) | 59 (49.2%) |
| Type of surgery | ||
| ENT, ophthalamic, oral surgery and minor surgery | 732 (15.3%) | 9 (7.5%) |
| Hepatobiliary pancreatic splenic surgery | 967 (20.2%) | 19 (15.8%) |
| Orthopedic surgery | 474 (9.9%) | 11 (9.2%) |
| Pelvic surgery | 618 (12.9%) | 15 (12.5%) |
| Nervous system surgery | 697 (14.5%) | 14 (11.7%) |
| Gastrointestinal surgery | 764 (15.9%) | 30 (25%) |
| Thoracic and vascular surgery | 542 (11.3%) | 22 (18.3%) |
2.2. 主要不良心脏事件的潜在危险因素
采用逻辑回归模型分析低风险异常心电图组MACE的显著独立危险因素，包括冠状动脉疾病（OR 2.74 ［95% CI 1.46-5.14］ P=0.002）、胸外科及血管外科手术（OR 3.25 ［95% CI 1.72-6.11］ P<0.001）、血红蛋白异常（OR 4.83 ［95% CI 1.55-15.07］ P=0.007）、白细胞异常（OR 3.88 ［95% CI 1.79-8.41］ P<0.001）、肌酐异常（OR 3.63 ［95% CI 1.73-7.62］ P<0.001）和D-二聚体异常（OR 3.76 ［95% CI 2.10-6.72］ P<0.001）（表4）。高风险异常心电图组MACE的显著独立危险因素包括心律失常（OR 2.22 ［95% CI 1.28-3.87］ P=0.005）、肾功能不全（OR 3.85 ［95% CI 1.14-12.98］ P=0.03）、葡萄糖（OR 1.79 ［95% CI 1.02-3.14］ P=0.042）、D-二聚体（OR 3.94 ［95% CI 2.19-7.07］ P<0.001）和胃肠外科手术（OR 2.03 ［95% CI 1.11-3.70］ P=0.021，表5）。
表4.
低危异常心电图组MACE的风险预测因素（开发队列）
Tab.4 Risk predictors of MACE in patients with low-risk abnormal ECG in model development cohort
| Characteristic | MACE No. (%) (n=3010) | OR (univariable) | OR (multivariable) | |
|---|---|---|---|---|
| Negative (n=2949) | Positive (n=61) | |||
| Gender | ||||
| Female | 1281 (43.4%) | 22 (36.1%) | 1 [Reference] | - |
| Male | 1668 (56.6%) | 39 (63.9%) | 1.36 (0.80-2.31, P=0.252) | - |
| Age (year) | ||||
| <75 | 2404 (81.5%) | 42 (68.9%) | 1 [Reference] | 1 [Reference] |
| ≥75 | 545 (18.5%) | 19 (31.1%) | 2.00 (1.15-3.46, P=0.014) | 1.52 (0.83-2.77, P=0.174) |
| BMI (kg/m2) | ||||
| 18-24 | 1240 (42%) | 27 (44.3%) | 1 [Reference] | - |
| <18 | 82 (2.8%) | 2 (3.3%) | 1.12 (0.26-4.79, P=0.878) | - |
| >24 | 1627 (55.2%) | 32 (52.5%) | 0.90 (0.54-1.52, P=0.700) | - |
| Medical condition | ||||
| Hypertension | 1399 (47.4%) | 35 (57.4%) | 1.49 (0.89-2.49, P=0.126) | - |
| Cerebrovascular disease | 218 (7.4%) | 6 (9.8%) | 1.37 (0.58-3.21, P=0.473) | - |
| Diabetes | 730 (24.8%) | 13 (21.3%) | 0.82 (0.44-1.53, P=0.538) | - |
| Coronary artery disease | 346 (11.7%) | 19 (31.1%) | 3.40 (1.96-5.92, P<0.001) | 2.74 (1.46-5.14, P=0.002) |
| Arrhythmia | 425 (14.4%) | 11 (18%) | 1.31 (0.67-2.53, P=0.428) | - |
| Valvular heart disease | 11 (0.4%) | 1 (1.6%) | 4.45 (0.57-35.03, P=0.156) | - |
| Myocardial infarction | 28 (0.9%) | 4 (6.6%) | 7.32 (2.49-21.56, P<0.001) | 1.45 (0.39-5.41, P=0.584) |
| Congestive heart failure | 3 (0.1%) | 2 (3.3%) | 33.29 (5.46-202.93, P<0.001) | 32.50 (4.44-237.91, P<0.001) |
| Hepatic insufficiency | 165 (5.6%) | 3 (4.9%) | 0.87 (0.27-2.81, P=0.820) | - |
| Renal insufficiency | 43 (1.5%) | 1 (1.6%) | 1.13 (0.15-8.31, P=0.907) | - |
| RBC (1012/L) | ||||
| 3.5-5.5 | 2722 (92.3%) | 47 (77%) | 1 [Reference] | 1 [Reference] |
| >5.5 | 30 (1%) | 0 (0%) | 0.00 (0.00-Inf, P=0.985) | 0.00 (0.00-Inf, P=0.982) |
| <3.5 | 197 (6.7%) | 14 (23%) | 4.12 (2.23-7.61, P<0.001) | 2.49 (0.95-6.50, P=0.062) |
| PLT (109/L) | ||||
| 100-300 | 2604 (88.3%) | 52 (85.2%) | 1 [Reference] | - |
| <100 | 69 (2.3%) | 0 (0%) | 0.00 (0.00-Inf, P=0.977) | - |
| >300 | 276 (9.4%) | 9 (14.8%) | 1.63 (0.80-3.35, P=0.181) | - |
| HGB (g/L) | ||||
| 110-160 | 2555 (86.6%) | 42 (68.9%) | 1 [Reference] | 1 [Reference] |
| >160 | 80 (2.7%) | 4 (6.6%) | 3.04 (1.06-8.69, P=0.038) | 4.83 (1.55-15.07, P=0.007) |
| <110 | 314 (10.6%) | 15 (24.6%) | 2.91 (1.59-5.30, P<0.001) | 0.86 (0.34-2.15, P=0.750) |
| WBC (109/L) | ||||
| 4-10 | 2582 (87.6%) | 47 (77%) | 1 [Reference] | 1 [Reference] |
| <4 | 262 (8.9%) | 4 (6.6%) | 0.84 (0.30-2.35, P=0.738) | 0.97 (0.33-2.83, P=0.951) |
| >10 | 105 (3.6%) | 10 (16.4%) | 5.23 (2.57-10.64, P<0.001) | 3.88 (1.79-8.41, P<0.001) |
| Cr (µmmol/L) | ||||
| 44-110 | 2781 (94.3%) | 48 (78.7%) | 1 [Reference] | 1 [Reference] |
| <44 | 40 (1.4%) | 2 (3.3%) | 2.90 (0.68-12.33, P=0.150) | 1.65 (0.31-8.73, P=0.556) |
| >110 | 128 (4.3%) | 11 (18%) | 4.98 (2.53-9.82, P<0.001) | 3.63 (1.73-7.62, P<0.001) |
| GLU (mmol/L) | ||||
| 3.4-6.1 | 2340 (79.3%) | 47 (77%) | 1 [Reference] | - |
| <3.4 | 13 (0.4%) | 0 (0%) | 0.00 (0.00-Inf, P=0.985) | - |
| >6.1 | 596 (20.2%) | 14 (23%) | 1.17 (0.64-2.14, P=0.611) | - |
| APTT (s) | ||||
| ≤40 | 2541 (86.2%) | 51 (83.6%) | 1 [Reference] | - |
| >40 | 408 (13.8%) | 10 (16.4%) | 1.22 (0.62-2.42, P=0.568) | - |
| D-dimer (ng/mL) | ||||
| ≤0.5 | 2097 (71.1%) | 21 (34.4%) | 1 [Reference] | 1 [Reference] |
| >0.5 | 852 (28.9%) | 40 (65.6%) | 4.69 (2.75-8.00, P<0.001) | 3.76 (2.10-6.72, P<0.001) |
| Type of surgery | ||||
| ENT, ophthalamic, oral surgery and minor surgery | 446 (15.1%) | 5 (8.2%) | 0.50 (0.20-1.26, P=0.141) | - |
| Hepatobiliary pancreatic splenic surgery | 604 (20.5%) | 9 (14.8%) | 0.67 (0.33-1.37, P=0.275) | - |
| Orthopedic surgery | 298 (10.1%) | 2 (3.3%) | 0.30 (0.07-1.24, P=0.097) | - |
| Pelvic surgery | 373 (12.6%) | 10 (16.4%) | 1.35 (0.68-2.69, P=0.387) | - |
| Nervous system surgery | 430 (14.6%) | 6 (9.8%) | 0.64 (0.27-1.49, P=0.301) | - |
| Gastrointestinal surgery | 471 (16%) | 13 (21.3%) | 1.42 (0.77-2.65, P=0.264) | - |
| Thoracic and vascular surgery | 327 (11.1%) | 16 (26.2%) | 2.85 (1.59-5.10, P<0.001) | 3.25 (1.72-6.11, P<0.001) |
表5.
高危异常心电图组MACE的风险预测因素（开发队列）
Tab.5 Risk predictors of MACE in patients with high-risk abnormal ECG in model development cohort
| Characteristic | MACE No. (%) (n=1904) | OR (univariable) | OR (multivariable) | |
|---|---|---|---|---|
| Negative (n=1845) | Positive (n=59) | |||
| Gender | ||||
| Female | 854 (46.3%) | 33 (55.9%) | 1 [Reference] | 1 [Reference] |
| Male | 991 (53.7%) | 26 (44.1%) | 0.68 (0.40-1.14, P=0.146) | － |
| Age (year) | ||||
| <75 | 1454 (78.8%) | 38 (64.4%) | 1 [Reference] | 1 [Reference] |
| ≥75 | 391 (21.2%) | 21 (35.6%) | 2.06 (1.19-3.54, P=0.009) | 1.42 (0.79-2.54, P=0.239) |
| Facility | 28 (1.5%) | 1 (1.7%) | 1.12 (0.15-8.36, P=0.913) | － |
| ASA grade | ||||
| Ⅰ | 12 (0.7%) | 0 (0%) | 1 [Reference] | － |
| Ⅱ | 1365 (74%) | 31 (52.5%) | － | － |
| Ⅲ | 451 (24.4%) | 24 (40.7%) | － | － |
| Ⅳ | 17 (0.9%) | 4 (6.8%) | － | － |
| BMI (kg/m2) | ||||
| 18-24 | 779 (42.2%) | 18 (30.5%) | 1 [Reference] | |
| <18 | 50 (2.7%) | 1 (1.7%) | 0.87 (0.11-6.62, P=0.889) | － |
| >24 | 1016 (55.1%) | 40 (67.8%) | 1.70 (0.97-2.99, P=0.064) | － |
| Smoking | 143 (7.8%) | 2 (3.4%) | 0.42 (0.10-1.73, P=0.228) | － |
| Drinking | 444 (24.1%) | 10 (16.9%) | 0.64 (0.32-1.28, P=0.210) | － |
| Medical condition | ||||
| Hypertension | 1018 (55.2%) | 37 (62.7%) | 1.37 (0.80-2.33, P=0.253) | － |
| Cerebrovascular disease | 170 (9.2%) | 5 (8.5%) | 0.91 (0.36-2.31, P=0.847) | － |
| Diabetes | 489 (26.5%) | 19 (32.2%) | 1.32 (0.76-2.30, P=0.331) | － |
| Coronary artery disease | 343 (18.6%) | 15 (25.4%) | 1.49 (0.82-2.71, P=0.189) | － |
| Arrhythmia | 389 (21.1%) | 25 (42.4%) | 2.75 (1.62-4.67, P<0.001) | 2.03 (1.13-3.65, P=0.017) |
| Valvular heart disease | 15 (0.8%) | 2 (3.4%) | 4.28 (0.96-19.16, P=0.057) | － |
| Myocardial infarction | 50 (2.7%) | 2 (3.4%) | 1.26 (0.30-5.30, P=0.753) | － |
| Congestive heart failure | 7 (0.4%) | 2 (3.4%) | 9.21 (1.87-45.33, P=0.006) | 2.36 (0.37-15.04, P=0.365) |
| COPD | 36 (2%) | 1 (1.7%) | 0.87 (0.12-6.43, P=0.888) | － |
| Malignant tumor | 127 (6.9%) | 2 (3.4%) | 0.47 (0.11-1.97, P=0.304) | － |
| Hepatic insufficiency | 98 (5.3%) | 4 (6.8%) | 1.30 (0.46-3.65, P=0.623) | － |
| Renal insufficiency | 23 (1.2%) | 4 (6.8%) | 5.76 (1.93-17.22, P=0.002) | 3.57 (1.03-12.45, P=0.045) |
| Peripheral artery disease | 47 (2.5%) | 3 (5.1%) | 2.05 (0.62-6.78, P=0.240) | － |
| Cardiac intervention | 119 (6.4%) | 4 (6.8%) | 1.05 (0.38-2.96, P=0.919) | － |
| RBC (1012/L) | ||||
| 3.5-5.5 | 1680 (91.1%) | 50 (84.7%) | 1 [Reference] | 1 [Reference] |
| >5.5 | 18 (1%) | 1 (1.7%) | 1.87 (0.24-14.26, P=0.547) | － |
| <3.5 | 147 (8%) | 8 (13.6%) | 1.83 (0.85-3.93, P=0.122) | － |
| PLT (109/L) | ||||
| 100-300 | 1584 (85.9%) | 51 (86.4%) | 1 [Reference] | 1 [Reference] |
| <100 | 45 (2.4%) | 0 (0%) | － | － |
| >300 | 216 (11.7%) | 8 (13.6%) | 1.15 (0.54-2.46, P=0.718) | － |
| HGB (g/L) | ||||
| 110-160 | 1576 (85.4%) | 48 (81.4%) | 1 [Reference] | 1 [Reference] |
| >160 | 54 (2.9%) | 1 (1.7%) | 0.61 (0.08-4.49, P=0.626) | － |
| <110 | 215 (11.7%) | 10 (16.9%) | 1.53 (0.76-3.06, P=0.233) | － |
| HCT (%) | ||||
| 35-50 | 1457 (79%) | 43 (72.9%) | 1 [Reference] | 1 [Reference] |
| >50 | 13 (0.7%) | 0 (0%) | － | － |
| <35 | 375 (20.3%) | 16 (27.1%) | 1.45 (0.81-2.60, P=0.217) | － |
| CRP (mg/L) | ||||
| ≤8 | 1810 (98.1%) | 58 (98.3%) | 1 [Reference] | 1 [Reference] |
| >8 | 35 (1.9%) | 1 (1.7%) | 0.89 (0.12-6.62, P=0.911) | － |
| WBC (109/L) | ||||
| 4-10 | 1614 (87.5%) | 53 (89.8%) | 1 [Reference] | 1 [Reference] |
| <4 | 155 (8.4%) | 2 (3.4%) | 0.39 (0.09-1.63, P=0.198) | － |
| >10 | 76 (4.1%) | 4 (6.8%) | 1.60 (0.57-4.54, P=0.375) | － |
| ALB (g/L) | ||||
| 35-55 | 1662 (90.1%) | 48 (81.4%) | 1 [Reference] | 1 [Reference] |
| <35 | 183 (9.9%) | 11 (18.6%) | 2.08 (1.06-4.08, P=0.033) | 1.12 (0.55-2.31, P=0.751) |
| Cr (µmmol/L) | ||||
| 44-110 | 1725 (93.5%) | 53 (89.8%) | 1 [Reference] | 1 [Reference] |
| <44 | 30 (1.6%) | 2 (3.4%) | 2.17 (0.51-9.32, P=0.297) | － |
| >110 | 90 (4.9%) | 4 (6.8%) | 1.45 (0.51-4.09, P=0.486) | － |
| Glu (mmol/L) | ||||
| 3.4-6.1 | 1420 (77%) | 38 (64.4%) | 1 [Reference] | 1 [Reference] |
| <3.4 | 13 (0.7%) | 0 (0%) | － | 0.00 (0.00-Inf, P=0.984) |
| Characteristic | MACE No. (%) (n=1904) | OR (univariable) | OR (multivariable) | |
|---|---|---|---|---|
| Negative (n=1845) | Positive (n=59) | |||
| >6.1 | 412 (22.3%) | 21 (35.6%) | 1.90 (1.11-3.28, P=0.020) | 1.67 (0.95-2.96, P=0.077) |
| K (mmol/L) | ||||
| 3.5-5.5 | 1790 (97%) | 57 (96.6%) | 1 [Reference] | 1 [Reference] |
| <3.5 | 54 (2.9%) | 2 (3.4%) | 1.16 (0.28-4.89, P=0.837) | － |
| >5.5 | 1 (0.1%) | 0 (0%) | － | － |
| TC (mmol/L) | ||||
| 3.1-6.2 | 1009 (54.7%) | 27 (45.8%) | 1 [Reference] | 1 [Reference] |
| <3.1 | 785 (42.5%) | 29 (49.2%) | 1.38 (0.81-2.35, P=0.235) | － |
| >6.2 | 51 (2.8%) | 3 (5.1%) | 2.20 (0.65-7.49, P=0.208) | － |
| TG (mmol/L) | ||||
| 1.7-2.3 | 165 (8.9%) | 5 (8.5%) | 1 [Reference] | 1 [Reference] |
| <1.7 | 1564 (84.8%) | 50 (84.7%) | 1.05 (0.41-2.68, P=0.910) | － |
| >2.3 | 116 (6.3%) | 4 (6.8%) | 1.14 (0.30-4.33, P=0.850) | － |
| HDL-C (mmol/L) | ||||
| 1.0-1.5 | 1327 (71.9%) | 45 (76.3%) | 1 [Reference] | 1 [Reference] |
| <1 | 375 (20.3%) | 8 (13.6%) | 0.63 (0.29-1.35, P=0.232) | － |
| >1.5 | 143 (7.8%) | 6 (10.2%) | 1.24 (0.52-2.95, P=0.631) | － |
| LDL-C (mmol/L) | ||||
| 2.1-3.4 | 1331 (72.1%) | 39 (66.1%) | 1 [Reference] | 1 [Reference] |
| <2.1 | 269 (14.6%) | 9 (15.3%) | 1.14 (0.55-2.38, P=0.724) | － |
| >3.4 | 245 (13.3%) | 11 (18.6%) | 1.53 (0.77-3.03, P=0.221) | － |
| SOD (U/mg protein) | ||||
| 110-215 | 1818 (98.5%) | 59 (100%) | 1 [Reference] | 1 [Reference] |
| >215 | 17 (0.9%) | 0 (0%) | － | － |
| <110 | 10 (0.5%) | 0 (0%) | － | － |
| LP(a) (mg/L) | ||||
| ≤300 | 1573 (85.3%) | 56 (94.9%) | 1 [Reference] | 1 [Reference] |
| >300 | 272 (14.7%) | 3 (5.1%) | 0.31 (0.10-1.00, P=0.049) | 0.28 (0.08-0.91, P=0.034) |
| TT ( s) | ||||
| ≤14 | 24 (1.3%) | 0 (0%) | 1 [Reference] | 1 [Reference] |
| >14 | 1821 (98.7%) | 59 (100%) | － | － |
| APTT (s) | ||||
| ≤40 | 1570 (85.1%) | 49 (83.1%) | 1 [Reference] | 1 [Reference] |
| >40 | 275 (14.9%) | 10 (16.9%) | 1.17 (0.58-2.33, P=0.665) | － |
| PT ( s) | ||||
| ≤14 | 1549 (84%) | 52 (88.1%) | 1 [Reference] | 1 [Reference] |
| >14 | 296 (16%) | 7 (11.9%) | 0.70 (0.32-1.57, P=0.390) | － |
| INR | ||||
| ≤1 | 696 (37.7%) | 23 (39%) | 1 [Reference] | 1 [Reference] |
| >1 | 1149 (62.3%) | 36 (61%) | 0.95 (0.56-1.61, P=0.844) | － |
| FIB (g/L) | ||||
| 2-4 | 1379 (74.7%) | 40 (67.8%) | 1 [Reference] | － |
| <2 | 24 (1.3%) | 0 (0%) | － | |
| >4 | 442 (24%) | 19 (32.2%) | 1.48 (0.85-2.59, P=0.166) | － |
| D-dimer (ng/mL) | ||||
| ≤0.5 | 1233 (66.8%) | 17 (28.8%) | 1 [Reference] | 1 [Reference] |
| >0.5 | 612 (33.2%) | 42 (71.2%) | 4.98 (2.81-8.82, P<0.001) | 3.81 (2.09-6.93, P<0.001) |
| Medication usage situation | ||||
| ACEI | 80 (4.3%) | 5 (8.5%) | 2.04 (0.80-5.25, P=0.138) | － |
| ARB | 224 (12.1%) | 12 (20.3%) | 1.85 (0.97-3.54, P=0.064) | － |
| Statin | 151 (8.2%) | 9 (15.3%) | 2.02 (0.97-4.19, P=0.059) | － |
| Bette | 17 (0.9%) | 1 (1.7%) | 1.85 (0.24-14.17, P=0.552) | － |
| Diuretic | 137 (7.4%) | 6 (10.2%) | 1.41 (0.60-3.34, P=0.433) | － |
| Anticoagulant | 219 (11.9%) | 13 (22%) | 2.10 (1.12-3.95, P=0.021) | 1.07 (0.51-2.23, P=0.856) |
| Antiplatelet drugs | 212 (11.5%) | 7 (11.9%) | 1.04 (0.47-2.31, P=0.929) | － |
| Beta blockers | 248 (13.4%) | 16 (27.1%) | 2.40 (1.33-4.32, P=0.004) | 1.52 (0.78-2.93, P=0.215) |
| Calcium channel blocker | 600 (32.5%) | 22 (37.3%) | 1.23 (0.72-2.11, P=0.443) | － |
| Type of surgery | ||||
| ENT, ophthalamic, oral surgery and minor surgery | 286 (15.5%) | 4 (6.8%) | 0.40 (0.14-1.10, P=0.076) | － |
| Hepatobiliary pancreatic splenic surgery | 363 (19.7%) | 10 (16.9%) | 0.83 (0.42-1.66, P=0.604) | － |
| Orthopedic surgery | 176 (9.5%) | 9 (15.3%) | 1.71 (0.83-3.53, P=0.149) | － |
| Pelvic surgery | 245 (13.3%) | 5 (8.5%) | 0.60 (0.24-1.53, P=0.287) | － |
| Nervous system surgery | 267 (14.5%) | 8 (13.6%) | 0.93 (0.44-1.98, P=0.845) | － |
| Gastrointestinal surgery | 293 (15.9%) | 17 (28.8%) | 2.14 (1.20-3.82, P=0.010) | 2.17 (1.18-3.99, P=0.013) |
| Thoracic and vascular surgery | 215 (11.7%) | 6 (10.2%) | 0.86 (0.36-2.02, P=0.726) | － |
GLU: Glucose; ALB: Albumin; TC: Total cholesterol; TG: Triglycerides; HDL-C: High-density lipoprotein cholesterol; LDL-C: Low-density lipoprotein cholesterol; LP(a): lipoprotein a; FIB: Fibronectin; INR: International normalized ratio.
2.3. 列线图的构建
根据模型中各预测因素对结局变量的贡献度及各影响因素的评分值，分配评分表：评分低于8分归类为低风险，8~17分视为中风险，超过17分则提示高风险（图1）。本研究表明，当患者在低风险心电图异常中的累计评分超过8分时，应进行术前心内科会诊。
图1.
低危异常心电图危险因素评分表
Fig.1 Risk factor scoring table for low-risk abnormal ECG.
2.4. 模型的建立与验证
基于从低风险异常ECG开发队列中筛选的6个风险因素进行模型验证，开发队列AUC值为0.786，验证队列AUC值为0.785（图2A），表明模型具有较好的稳定性。开发队列Hosmer-Lemeshow检验（χ2=4.168；P= 0.842）、验证队列Hosmer-Lemeshow检验（χ2=1.727；P=0.988），通过Hosmer-Lemeshow检验，显示预测值和实际值之间没有显著差异。
图 2.
预测模型诊断效能的受试者工作特征曲线
Fig.2 Receiver operating characteristic curves of diagnostic performance of the prediction models.
低风险异常ECG的开发队列中，模型与理想模型之间的最大偏差Emax为0.095，最小偏差Eavg为0.002，表明该模型具有高准确性。不可靠性检验显示S：p值为0.985，显著性水平高于0.05，表明通过了校准测试。
基于从高风险异常ECG的开发队列中筛选出的5个风险因素进行模型验证，模型的预测能力稳定，开发队列AUC值为0.769，验证队列AUC值为0.742（图2B）。开发队列Hosmer-Lemeshow检验（χ2=2.3；P= 0.97）、验证队列Hosmer-Lemeshow检验（χ2=3.523；P=0.897）。通过Hosmer-Lemeshow检验，显示预测值与真实值之间无显著差异。
2.5. 决策曲线分析
对于ECG异常但风险较低的患者群体，DCA结果显示预测MACE生存的阈值为0.02，且加入会诊后未观察到显著净效益（图3A）。对于ECG异常且存在特定风险因素的低风险患者群体，DCA结果显示预测MACE生存的阈值为0.229（图3B），加入会诊后观察到显著净效益。DCA结果显示，对于ECG异常的高风险个体，预测MACE生存的阈值为0.3，加入会诊后观察到显著净效益（图3C）。
图3.
决策曲线分析
Fig.3 Decision curve analysis (DCA). A: DCA for simple low-risk abnormal ECGs; B: DCA for low-risk abnormal ECGs with certain risk factors; C: DCA for high-risk abnormal ECGs.
3. 讨论
本研究发现并非所有异常ECG均需术前心内科会诊。在具有临床危险因素且合并低风险异常ECG或高风险异常ECG的患者中，术前心内科会诊与术后MACE发生率降低相关。然而，在ECG异常为低风险且无临床危险因素的患者中，心内科会诊的获益微乎其微或不存在。
术后MACE的发生对患者具有灾难性影响，可导致严重心脏疾病的发生发展甚至死亡［15］。尽管学界普遍认为心电图异常需在术前进行心内科会诊［14］，但有研究指出并非所有病例都必须如此［16］。不必要的围手术期心血管评估与管理可能增加医疗费用并延误手术时机［8， 17］。然而，若未进行会诊也可能导致MACE发生率升高［18］并增加法律风险［19］。这为患者围手术期管理带来了未知因素。目前关于哪些特定心电图异常情况需要心内科会诊以降低围手术期MACE发生率的研究仍较为有限。本研究在范围上更具综合性与针对性。
本研究显示，对于ECG结果异常但无合并症、低风险的患者，术前无需进行心内科会诊。这些心律异常通常为良性，可能由ECG检查时的紧张情绪［20， 21］或早期复极化［22］等因素引起。心脏结构的轻微生理性异常也不提示病理状态［17， 23， 24］。同样，轻度病理异常如一度房室传导阻滞或局部束支传导阻滞，对心脏功能影响甚微，且不会显著影响患者日常活动［25， 26］。基于研究结果，这类患者无需在术前接受心内科会诊，因为其心脏功能可耐受围手术期创伤应激，尽管ECG结果异常，但其心脏状况仍保持稳定，此期间无显著风险。此类患者术后发生MACE风险较低，因此术前心内科会诊的获益微乎其微。
当患者患有冠状动脉疾病、D-二聚体水平升高或血红蛋白水平偏高时，提示其可能存在心肌灌注不足或高凝状态，从而增加心肌梗死风险［27， 28］。当患者血红蛋白或肌酐水平偏低时，则表明其营养状况较差，且可能对围手术期耐受性降低［29， 30］。非心脏胸外科手术及大型血管手术具有循环波动、显著出血、胸腔压力改变及纵隔摆动的风险［31］，这些因素会增加MACE的发生风险［32-34］。根据我们的研究结果，在低风险ECG异常病例中，当上述风险因素的累积评分超过8分时，建议进行心内科会诊。术前心内科会诊可提醒麻醉医生和外科医生更密切地监测患者的生命体征［35， 36］。
本研究证实，对于ECG异常且具有高风险的患者，在手术前提供心内科会诊至关重要。此类ECG异常通常提示存在严重心律失常、心肌缺血及其他问题，表明心脏功能受损［37， 38］。此外，我们发现，当以下因素与高风险ECG异常同时存在时，MACE的发生率会显著增加。这五个高风险因素包括：心律失常病史、肾功能不全病史、空腹血糖水平升高、D-二聚体水平升高以及接受胃肠道手术。明确的心律失常病史提示患者存在心脏功能障碍［38］。肾功能不全和空腹血糖水平升高往往伴随着心血管系统风险［39， 40］。此外，胃肠道手术术后常导致体液或电解质失衡，这可能增加MACE的发生率［41］。通过心内科会诊，可有效提醒医生关注相关问题，并与患者及其家属进行沟通，使其理解相关风险并作出知情决策［35， 36］。
本研究结果表明，并非所有异常心电图均需在手术前进行心内科会诊，必须对每个病例进行个体化评估以确定是否需要会诊，此举有助于避免医疗资源浪费并更好地保障患者安全。未来研究可探索优化会诊流程以最大化患者获益。
Acknowledgments
中关村生物医学大数据中心(中关村大数据产业联盟，中国北京)委托进行了独立数据分析，该中心对数据进行了格式化处理并进行了初步分析。王磊及其同事协助完成了数据收集及统计分析,对他们的贡献表示感谢!
基金资助
国家重点研发计划（2018YFC2001900）
Supported by the National Key Research and Development Program of China (2018YFC2001900).
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