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The incidences of acute mesenteric ischaemia vary greatly depending on the population and diagnostic activity
Critical Care ( IF 15.1 ) Pub Date : 2024-03-18 , DOI: 10.1186/s13054-024-04870-x
Annika Reintam Blaser , Kadri Tamme , Joel Starkopf , Alastair Forbes , Marko Murruste , Peep Talving , Stefan Acosta , Martin Björck

We much appreciate the interest of Drs Gazelli and Nacher regarding the AMESI study [1, 2], and for their effort to debate the difficulties in establishing a “true incidence” of acute mesenteric ischaemia (AMI) [3]. To address the question of true incidence, we first need to acknowledge the multifaceted nature of AMI. The main drivers of arterial occlusive AMI are cardiac arrhythmias (that increase exponentially with age) explaining most embolic occlusions, and smoking, which is the most important risk factor for thrombotic occlusion [4,5,6]. The non-occlusive arterial AMI (NOMI) is mainly associated with intensive care practices, as well as the incidences of sepsis and heart surgery [1, 6]. The main risk factors for venous AMI are obesity, previous venous thromboembolism and genetic thrombophilia [1, 6, 7]. Given this complex pathophysiological background, it is not surprising that the crude incidence rates vary depending on the studied population [8]. Those risk factors, as well as demography, likely vary greatly between regions, countries and hospitals across the world. The estimated incidence of AMI and its subtypes is unknown in most countries, except in Estonia, Sweden, and Finland, where population-based studies have recently been conducted, the latter two also declaring autopsy rates in their respective populations [9,10,11]. As the authors rightly imply, we lack the detailed knowledge on the incidence of the different entities of AMI in low–middle-income countries. A parallel may be drawn with the cardiovascular disease with largely variable incidences and trends between countries, where the burden in high-income countries may decline, while increasing in low–middle-income countries [12, 13], perhaps with increasing incidence of AMI.

Considering these diverging risk factors, which result in different incidences of AMI, there are likely relevant differences in the capabilities of healthcare systems to identify and treat AMI. The awareness of AMI may vary, and it is likely that a number of AMI cases went undetected during the AMESI study. However, this also mirrors the true current situation, as the detected cases were included in the study. Sites having an intensivist as a principal investigator were possibly more likely to identify patients with NOMI. Interestingly, the only specialist centre in the AMESI study did not identify any patients with NOMI, despite having the highest rate of other subtypes of AMI included. The main diagnostic modality, a true game-changer during the recent decades, is the tri-phasic computed tomography angiography (CTA) [6]. This is a rather expensive diagnostic modality, and it is not readily available in all low–middle-income countries, especially not in rural areas. The frequency of post-mortem examinations is low in all countries, in fact making it impossible to identify the true incidence of AMI, because of inability to identify AMI as an undetected cause of death among those not diagnosed alive.

When planning the AMESI study, we made an effort to include different types of hospitals, from peripheral district hospitals to one national referral centre for intestinal ischaemia. The 32 hospitals are located in three continents: Asia, South America and Europe. This variability will affect the individual incidences, but also add to the generalizability of the conclusions. The fact that the AMESI is by far the largest prospective study ever performed on AMI does make it possible to perform several subgroup analyses. Multiple such are underway, we have only published our first analysis [1]. However, regarding the true incidence of AMI, the AMESI study is probably just as good as it gets in hospital settings.

Not applicable.

  1. Reintam Blaser A, Mändul M, Björck M, Acosta S, Bala M, Bodnar Z, et al. Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI study). Crit Care. 2024;28(1):32.

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We thank all the AMESI study investigators.

The AMESI study was funded by the Estonian Research Council (Grant PRG1255).

Authors and Affiliations

  1. Institute of Clinical Medicine, University of Tartu, Tartu, Estonia

    Annika Reintam Blaser, Kadri Tamme, Joel Starkopf, Alastair Forbes, Marko Murruste, Peep Talving & Martin Björck

  2. Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland

    Annika Reintam Blaser

  3. Tartu University Hospital, Tartu, Estonia

    Kadri Tamme, Joel Starkopf, Alastair Forbes & Marko Murruste

  4. North Estonia Medical Centre, Tallinn, Estonia

    Peep Talving

  5. Department of Clinical Sciences, Lund University, Malmö, Sweden

    Stefan Acosta

  6. Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden

    Martin Björck

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Contributions

MB prepared the first draft of the manuscript; all authors read, revised and approved the final manuscript.

Corresponding author

Correspondence to Annika Reintam Blaser.

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Competing interests

ARB has received speaker or consultancy fees from Nestlé, VIPUN Medical, Nutricia Danone and Fresenius Kabi, and is holding a grant from Estonian Research Council (PRG1255). AF has received speaker fees from B Braun and Fresenius Kabi. JS, MM, KT, PT, SA and MB declare no conflicts of interest.

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Reintam Blaser, A., Tamme, K., Starkopf, J. et al. The incidences of acute mesenteric ischaemia vary greatly depending on the population and diagnostic activity. Crit Care 28, 85 (2024). https://doi.org/10.1186/s13054-024-04870-x

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中文翻译：
急性肠系膜缺血的发生率根据人群和诊断活动的不同而有很大差异

我们非常感谢 Gazelli 和 Nacher 博士对 AMESI 研究的兴趣 [1, 2]，并感谢他们努力讨论确定急性肠系膜缺血 (AMI)“真实发生率”的困难 [3]。为了解决真实发病率的问题，我们首先需要承认 AMI 的多方面性质。动脉闭塞性 AMI 的主要驱动因素是心律失常（随年龄呈指数增长）和吸烟，前者是大多数栓塞性闭塞的原因，后者是血栓性闭塞最重要的危险因素 [4,5,6]。非闭塞性动脉 AMI (NOMI) 主要与重症监护实践以及脓毒症和心脏手术的发生率有关 [1, 6]。静脉性 AMI 的主要危险因素是肥胖、既往静脉血栓栓塞史和遗传性血栓形成倾向 [1,6,7]。鉴于这种复杂的病理生理学背景，粗发病率根据研究人群的不同而变化也就不足为奇了[8]。这些风险因素以及人口特征可能在世界各地的地区、国家和医院之间存在很大差异。大多数国家 AMI 及其亚型的估计发病率未知，但爱沙尼亚、瑞典和芬兰除外，这些国家最近进行了基于人群的研究，后两个国家也公布了各自人群的尸检率 [9,10,11 ]。正如作者正确暗示的那样，我们缺乏对中低收入国家 AMI 不同实体的发病率的详细了解。与心血管疾病相似的是，各国之间的发病率和趋势差异很大，高收入国家的负担可能会下降，而中低收入国家的负担可能会增加[12, 13]，也许随着 AMI 发病率的增加。

考虑到这些不同的风险因素会导致不同的 AMI 发病率，医疗保健系统识别和治疗 AMI 的能力可能存在相关差异。对 AMI 的认识可能有所不同，并且在 AMESI 研究期间很可能有许多 AMI 病例未被发现。然而，这也反映了当前的真实情况，因为发现的病例已被纳入研究中。以重症监护医师作为主要研究者的研究中心可能更有可能识别出 NOMI 患者。有趣的是，AMESI 研究中唯一的专科中心没有发现任何 NOMI 患者，尽管其他 AMI 亚型的发病率最高。主要的诊断方式是三相计算机断层扫描血管造影（CTA），是近几十年来真正的游戏规则改变者[6]。这是一种相当昂贵的诊断方式，并非所有中低收入国家都能轻易获得，特别是在农村地区。所有国家的尸检频率都很低，事实上，这使得无法确定 AMI 的真实发病率，因为无法将 AMI 确定为未被诊断为活着的人中未被发现的死亡原因。

在规划 AMESI 研究时，我们努力纳入不同类型的医院，从外围地区医院到一个国家肠缺血转诊中心。这32家医院分布在三大洲：亚洲、南美洲和欧洲。这种变异性会影响个体发生率，但也会增加结论的普遍性。AMESI 是迄今为止对 AMI 进行的最大规模的前瞻性研究，这一事实确实使得进行多个亚组分析成为可能。多个此类研究正在进行中，我们仅发布了第一个分析 [1]。然而，就 AMI 的真实发生率而言，AMESI 研究可能与医院环境中的研究一样好。

不适用。

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下载参考资料

我们感谢所有 AMESI 研究人员。

AMESI 研究由爱沙尼亚研究委员会资助（Grant PRG1255）。

作者和单位

  1. 临床医学研究所，塔尔图大学，塔尔图爱沙尼亚

    Annika Reintam Blaser、Kadri Tamme、Joel Starkopf、Alastair Forbes、Marko Murruste、Peep Talving 和 Martin Björck

  2. 瑞士卢塞恩卢塞恩州立医院重症监护医学科

    安妮卡·雷因塔姆·布拉泽

  3. 塔尔图大学医院，塔尔图，爱沙尼亚

    卡德里·塔梅、乔尔·斯塔科普夫、阿拉斯泰尔·福布斯和马科·穆鲁斯特

  4. 北爱沙尼亚医疗中心，塔林，爱沙尼亚

    窥视塔尔文

  5. 临床科学系，隆德大学，马尔默瑞典

    斯特凡·阿科斯塔

  6. 外科科学系，血管外科，乌普萨拉大学，乌普萨拉瑞典

    马丁·比约克

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ARB 已从雀巢、VIPUN Medical、Nutricia Danone 和 Fresenius Kabi 获得演讲或咨询费用，并获得爱沙尼亚研究委员会 (PRG1255) 的资助。AF 已从 B Braun 和 Fresenius Kabi 收取演讲费用。JS、MM、KT、PT、SA 和 MB 声明不存在利益冲突。

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Reintam Blaser, A.、Tamme, K.、Starkopf, J.等人。急性肠系膜缺血的发生率根据人群和诊断活动的不同而有很大差异。重症监护 28 , 85 (2024)。https://doi.org/10.1186/s13054-024-04870-x

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