Hollander J E, Muttreja M R, Dalesandro M R, Shofer F S
Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia 19104-4283, USA.
J Am Coll Cardiol. 1999 Jul;34(1):95-105. doi: 10.1016/s0735-1097(99)00175-8.
We compared the predictive properties of P-selectin to creatine kinase, MB fraction (CK-MB) for detecting acute myocardial infarction (AMI), acute coronary syndromes (ACS) and serious cardiac events upon emergency department (ED) arrival.
Practioners detecting early diagnosis of ACS have focused on cardiac markers of myocardial injury. Plaque rupture/platelet aggregation precedes myocardial ischemia. Therefore, markers of platelet aggregation may detect ACS earlier than cardiac markers.
Consecutive patients with potential ACS presenting to an urban university ED were identified by research assistants who screened all ED patients between November 12, 1997 and January 31, 1998. Whole blood was drawn at presentation and 1 h later and rapidly stained and fixed for membrane P-selectin assay and plasma was separated for soluble P-selectin assay. Creatine kinase, MB fraction values were determined using standard immunoassay techniques. Clinical history and hospital course were followed daily. Outcomes were AMI, ACS (AMI and unstable angina) and serious cardiac events. Receiver operator characteristic curves were derived for CK-MB, and soluble and membrane-bound P-selectin to determine the optimal cutoff values. Predictive properties were calculated with 95% confidence intervals.
A total of 263 patients were enrolled. They had a mean age of 56.5+/-14 years; 52% were male. There were 22 patients with AMI; 87 patients with ACS and 54 patients with serious cardiac events. Creatine kinase, MB fraction had a higher specificity for detection of AMI, ACS and serious cardiac events than both soluble and membrane-bound P-selectin. At the time of ED presentation, the specificity of CK-MB, and soluble and membrane-bound P-selectin for AMI was 91% versus 76% versus 71%; for ACS, 95% versus 79% versus 71%, and for serious cardiac events, 91% versus 76% versus 72% (p < 0.05). The sensitivities for AMI were 50% versus 45% versus 32%; for ACS, 26% versus 35% versus 30%, and for serious cardiac events, 29% versus 35% versus 36%.
Although theoretically attractive, the use of soluble and membrane-bound P-selectin for risk stratification of chest pain patients at the time of ED presentation does not appear to have any advantages over the use of CK-MB.
我们比较了P选择素与肌酸激酶同工酶MB（CK-MB）在急诊科（ED）就诊时检测急性心肌梗死（AMI）、急性冠状动脉综合征（ACS）和严重心脏事件的预测特性。
检测ACS早期诊断的医生一直专注于心肌损伤的心脏标志物。斑块破裂/血小板聚集先于心肌缺血。因此，血小板聚集标志物可能比心脏标志物更早检测到ACS。
研究助理对1997年11月12日至1998年1月31日期间所有ED患者进行筛查，确定连续就诊于城市大学急诊科的潜在ACS患者。就诊时及1小时后采集全血，快速染色并固定用于膜P选择素检测，分离血浆用于可溶性P选择素检测。使用标准免疫测定技术测定肌酸激酶同工酶MB值。每天跟踪临床病史和住院过程。结局指标为AMI、ACS（AMI和不稳定型心绞痛）和严重心脏事件。绘制CK-MB、可溶性和膜结合P选择素的受试者工作特征曲线，以确定最佳临界值。计算预测特性的95%置信区间。
共纳入263例患者。他们的平均年龄为56.5±14岁；52%为男性。有22例AMI患者；87例ACS患者和54例严重心脏事件患者。肌酸激酶同工酶MB在检测AMI、ACS和严重心脏事件方面比可溶性和膜结合P选择素具有更高的特异性。在ED就诊时，CK-MB、可溶性和膜结合P选择素对AMI的特异性分别为91%、76%和71%；对ACS的特异性分别为95%、79%和71%，对严重心脏事件的特异性分别为91%、76%和72%（p<0.05）。对AMI的敏感性分别为50%、45%和32%；对ACS的敏感性分别为26%、35%和30%，对严重心脏事件的敏感性分别为29%、35%和36%。
虽然理论上有吸引力，但在ED就诊时使用可溶性和膜结合P选择素对胸痛患者进行风险分层似乎并不比使用CK-MB有任何优势。
