Singer Adam J, Thode Henry C, Green Gary B, Birkhahn Robert, Shapiro Nathan I, Cairns Charles, Baumann Brigitte M, Aghababian Richard, Char Douglas, Hollander Judd E
Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA.
Acad Emerg Med. 2009 Jun;16(6):488-94. doi: 10.1111/j.1553-2712.2009.00415.x. Epub 2009 Apr 23.
The objective was to determine the incremental benefit of a shortness-of-breath (SOB) point-of-care biomarker panel on the diagnostic accuracy of emergency department (ED) patients presenting with dyspnea.
Adult ED patients at 10 U.S. EDs with SOB were included. The physician's estimates of the pretest clinical probability of heart failure (HF), acute myocardial infarction (MI), and pulmonary embolism (PE) were recorded using deciles (0%-100%). Blood samples were analyzed using a SOB point-of-care biomarker panel (troponin I, myoglobin, creatinine kinase-myocardial band isoenzyme [CK-MB], D-dimer, and B-type natriuretic peptide [BNP]). Thirty-day follow-up for MI, HF, and PE was performed. Data were analyzed using logistic regression and receiver operating characteristics (ROC) curve analysis.
Of 301 patients, the mean (+/-standard deviation [SD]) age was 61 (+/-18) years; 56% were female, 58% were white, and 38% were African American. Diagnoses included MI (n = 54), HF (n = 91), and PE (n = 16) in a total of 129 (43%) of the patients. High pretest clinical certainty (>or=80%) identified 60 of these 129 (46.5%) cases. The SOB point-of-care biomarker panel identified 66 additional cases of MI (n = 24), HF (n = 31), and PE (n = 11). The overall adjusted sensitivity for any diagnosis was increased from 65% to 70% with the addition of the SOB point-of-care biomarker panel (difference = 5%, 95% CI = -1.1% to 11%) while specificity was increased from 82% to 83% (difference = 1%, 95% CI = -4% to 7%). The model containing pretest probability and the results of the SOB panel had an area under the curve (AUC) of 83.4% (95% CI = 78.4% to 88.5%), which was not significantly better than the AUC of 80.4% (95% CI = 75.1% to 85.7%) for clinical probability alone.
The addition of the SOB panel of markers did not improve the AUC for diagnosing the combined set of clinical conditions. Using the disease-specific SOB biomarkers increased the sensitivity on a disease-by-disease basis; however, specificity was reduced.
本研究旨在确定呼吸急促即时检测生物标志物组合对急诊科（ED）出现呼吸困难患者诊断准确性的增量效益。
纳入美国10家急诊科出现呼吸急促的成年患者。使用十分位数（0%-100%）记录医生对心力衰竭（HF）、急性心肌梗死（MI）和肺栓塞（PE）的预检临床概率估计值。使用呼吸急促即时检测生物标志物组合（肌钙蛋白I、肌红蛋白、肌酸激酶心肌带同工酶[CK-MB]、D-二聚体和B型利钠肽[BNP]）对血样进行分析。对MI、HF和PE进行30天随访。使用逻辑回归和受试者操作特征（ROC）曲线分析对数据进行分析。
301例患者中，平均（±标准差[SD]）年龄为61（±18）岁；56%为女性，58%为白人，38%为非裔美国人。诊断包括MI（n = 54）、HF（n = 91）和PE（n = 16），共129例（43%）患者。预检临床确定性高（≥80%）识别出这129例中的60例（46.5%）。呼吸急促即时检测生物标志物组合又识别出另外66例MI（n = 24）、HF（n = 31）和PE（n = 11）病例。添加呼吸急促即时检测生物标志物组合后，任何诊断的总体调整敏感性从65%提高到70%（差异 = 5%，95%CI = -1.1%至11%），而特异性从82%提高到83%（差异 = 1%，95%CI = -4%至7%）。包含预检概率和呼吸急促检测组合结果的模型曲线下面积（AUC）为83.4%（95%CI = 78.4%至88.5%），并不显著优于仅临床概率的AUC 80.4%（95%CI = 75.1%至85.7%）。
添加呼吸急促检测标志物组合并未改善诊断综合临床情况的AUC。使用特定疾病的呼吸急促生物标志物在逐个疾病基础上提高了敏感性；然而，特异性降低了。
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