Menown Ian B A, Mathew Thomas P, Gracey Helen M, Nesbitt G Selby, Murray Pamela, Young Ian S, Adgey A A Jennifer
Regional Medical Cardiology Centre, Royal Victoria Hospital, Belfast, Northern Ireland, UK.
Am Heart J. 2003 Jun;145(6):986-92. doi: 10.1016/S0002-8703(03)00169-8.
The independent predictive value of d-dimer and inflammatory markers for the risk of recurrent adverse events in patients with acute chest pain but normal levels of cardiac troponin I (cTnI) remains unclear.
We studied 391 patients admitted to the hospital in 1 year with acute ischemic-type chest pain. Creatine kinase-myocardial band isoenzyme (CK-MB) mass and cTnI levels were measured in initial and 12-hour samples. Soluble intercellular adhesion molecule (sICAM)-1, vascular cell adhesion molecule (sVCAM)-1, sP-selectin, sE-selectin, high sensitivity C-reactive protein (hsCRP), interleukin-6 (IL6), fibrinogen, and d-dimer levels were measured in initial samples. A 1-year incidence of death, myocardial infarction (MI), revascularization, or readmission with chest pain was determined (with death/MI as the primary end point).
Patients with normal levels of CK-MB(mass) and cTnI (195/391[50%]) were at a lower risk than patients with elevated levels of CK-MB(mass) or cTnI, but still had an important incidence of events (77/195[39%]). Marker elevation was defined as >75th percentile (upper quartile). Elevated d-dimer levels (>580 ng/mL) was predictive of death/MI (odds ratio, 5.4; 95% CI, 1.5-20.2; P =.005). Elevated sP-selectin levels (>152 ng/mL; odds ratio, 3.2; 95% CI, 0.9-11.6; P =.06) trended to increased death/MI rates, with weaker trends for elevated levels of hsCRP (>7.1 mg/L), IL6 (>10.7 pg/mL), and ST depression. Other markers, other electrocardiogram changes, or classic risk factors were not predictive of death/MI. With a multivariate analysis, d-dimer and sP-selectin were found to be of independent significance for death/MI after adjustment for inflammatory, hemostatic, and electrocardiogram markers and d-dimer after adjustment for classic risk factors.
Normal cTnI levels after acute chest pain does not confer absence of future risk. Concurrent assessment of d-dimer and inflammatory markers may improve risk stratification.
对于急性胸痛但心肌肌钙蛋白I（cTnI）水平正常的患者，D-二聚体和炎症标志物对复发性不良事件风险的独立预测价值仍不明确。
我们研究了1年内因急性缺血性胸痛入院的391例患者。在初始样本和12小时样本中测量肌酸激酶-心肌带同工酶（CK-MB）质量和cTnI水平。在初始样本中测量可溶性细胞间黏附分子（sICAM）-1、血管细胞黏附分子（sVCAM）-1、sP-选择素、sE-选择素、高敏C反应蛋白（hsCRP）、白细胞介素-6（IL6）、纤维蛋白原和D-二聚体水平。确定1年内心脏死亡、心肌梗死（MI）、血运重建或因胸痛再次入院的发生率（将死亡/MI作为主要终点）。
CK-MB（质量）和cTnI水平正常的患者（195/391[50%]）比CK-MB（质量）或cTnI水平升高的患者风险更低，但仍有重要的事件发生率（77/195[39%]）。标志物升高定义为>第75百分位数（上四分位数）。D-二聚体水平升高（>580 ng/mL）可预测死亡/MI（比值比，5.4；95%CI，1.5-20.2；P = 0.005）。sP-选择素水平升高（>152 ng/mL；比值比，3.2；95%CI，0.9-11.6；P = 0.06）有死亡/MI发生率增加的趋势，hsCRP（>7.1 mg/L）、IL6（>10.7 pg/mL）水平升高及ST段压低的趋势较弱。其他标志物、其他心电图改变或经典危险因素不能预测死亡/MI。多因素分析显示，在对炎症、止血和心电图标志物进行校正后，D-二聚体和sP-选择素对死亡/MI具有独立意义；在对经典危险因素进行校正后，D-二聚体也具有独立意义。
急性胸痛后cTnI水平正常并不能排除未来风险。同时评估D-二聚体和炎症标志物可能改善风险分层。
