Harrison Alex, Amundson Stanley
Division of Medical Education and General Internal Medicine, Scripps Mercy Hospital, San Diego, CA 92103, USA.
Am J Emerg Med. 2005 May;23(3):371-8. doi: 10.1016/j.ajem.2005.02.017.
The etiology of dyspnea can often be difficult to rapidly and accurately determine and can delay timely and appropriate therapies. The current literature reveals important diagnostic, prognostic, and therapeutic implications of several currently used biomarkers: sensitive d -dimer, myoglobin, creatine kinase-MB, cardiac troponins, and b-type natriuretic peptide. These biomarkers were found to have a high sensitivity and negative predictive value for rapidly ruling out potential serious etiologies of dyspnea, namely, pulmonary embolism (PE), acute myocardial infarction (AMI), and congestive heart failure (CHF). In the setting of a low to moderate pretest probability of PE, a negative sensitive d -dimer can rule out a PE with 97% accuracy. After 10 hours from the onset of symptoms, normal levels of myoglobin, creatine kinase-MB, and cardiac troponin I can rule out an AMI with greater than 96% accuracy. A b-type natriuretic peptide level less than 80 pg/mL can confidently rule out decompensated CHF with greater than 99% accuracy. However, no literature was found analyzing the use of these biomarkers in combination. A dyspnea biomarker panel could rapidly and accurately assist a clinician to rule out PE, AMI, and CHF. If a PE, AMI, or CHF is determined to be the cause of dyspnea, a biomarker panel could help risk stratify and help determine initial therapies. Subsequent clinical research is needed to corroborate this postulation.
呼吸困难的病因往往难以快速、准确地确定，可能会延误及时、恰当的治疗。当前文献揭示了几种目前使用的生物标志物在诊断、预后及治疗方面的重要意义：敏感的D-二聚体、肌红蛋白、肌酸激酶同工酶MB、心肌肌钙蛋白以及B型利钠肽。这些生物标志物被发现对于快速排除呼吸困难的潜在严重病因，即肺栓塞（PE）、急性心肌梗死（AMI）和充血性心力衰竭（CHF）具有较高的敏感性和阴性预测价值。在PE的验前概率为低至中度的情况下，D-二聚体阴性可排除PE，准确率达97%。症状出现10小时后，肌红蛋白、肌酸激酶同工酶MB及心肌肌钙蛋白I水平正常可排除AMI，准确率大于96%。B型利钠肽水平低于80 pg/mL可非常有把握地排除失代偿性CHF，准确率大于99%。然而，未发现有文献分析这些生物标志物的联合应用。一个呼吸困难生物标志物组合可以快速、准确地帮助临床医生排除PE、AMI和CHF。如果确定PE、AMI或CHF是呼吸困难的病因，一个生物标志物组合可有助于进行危险分层并确定初始治疗方案。后续需要进行临床研究来证实这一假设。
