Halim Sharif A, Mulgund Jyotsna, Chen Anita Y, Roe Matthew T, Peterson Eric D, Gibler W Brian, Ohman E Magnus, Newby L Kristin
Department of Medicine and the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715-7969, USA.
Circ Cardiovasc Qual Outcomes. 2009 May;2(3):199-206. doi: 10.1161/CIRCOUTCOMES.108.810127. Epub 2009 Apr 28.
Troponin elevation above the upper limit of normal (ULN) is diagnostic of myocardial infarction, but interpretation of "gray-zone" troponin elevations (1 to 1.5x ULN) remains uncertain. Using the CRUSADE database, we explored relationships between sex and treatment and outcomes among patients with troponin 1 to 1.5x ULN.
We compared treatment and outcomes among women and men using logistic generalized estimating equation method. Overall, 5049 of 85 671 (5.9%) non-ST-segment elevation acute coronary syndromes patients (2156 women, 2893 men) had troponin 1 to 1.5x ULN within 24 hours of presentation. Compared with troponin >1.5x ULN, "gray-zone" patients less often received all guidelines-indicated acute (mean composite score, 63% versus 72%) and discharge therapies (mean composite score, 73% versus 78%), but received them more frequently than patients with troponin <1x ULN (mean composite scores, 58% acute and 67% discharge). Among "gray-zone" patients, acute and discharge therapy use was similar between women and men, except acute aspirin (adjusted odds ratio, 0.80 [95% CI, 0.65 to 0.98]) and discharge angiotensin-converting enzyme inhibitors (adjusted odds ratio, 0.77 [95% CI, 0.67 to 0.88]). "Gray-zone" patients had lower mortality (2.3%) than the >1.5x ULN (4.5%) group but higher than the <1x ULN group (1.1%). Outcomes were similar among "gray-zone" women and men (adjusted odds ratios: death, 0.88 [95% CI, 0.58 to 1.35]; death/myocardial infarction, 0.77 [95% CI, 0.55 to 1.06]; transfusion, 1.04 [95% CI, 0.85 to 1.27]).
Patients with non-ST-segment elevation acute coronary syndromes and low-level troponin elevations had lower overall risk and received less aggressive guidelines-based treatment than those with greater troponin elevations, but treatment patterns were largely similar by sex across troponin elevation groups.
肌钙蛋白升高超过正常上限（ULN）可诊断心肌梗死，但对“灰色区”肌钙蛋白升高（1至1.5倍ULN）的解读仍不确定。利用CRUSADE数据库，我们探讨了肌钙蛋白在1至1.5倍ULN的患者中性别与治疗及预后之间的关系。
我们使用逻辑广义估计方程法比较了女性和男性的治疗及预后情况。总体而言，85671例非ST段抬高型急性冠状动脉综合征患者中有5049例（5.9%）（2156例女性，2893例男性）在就诊后24小时内肌钙蛋白为1至1.5倍ULN。与肌钙蛋白>1.5倍ULN的患者相比，“灰色区”患者较少接受所有指南推荐的急性治疗（平均综合评分，63%对72%）和出院治疗（平均综合评分，73%对78%），但比肌钙蛋白<1倍ULN的患者更频繁地接受这些治疗（平均综合评分，急性治疗为58%，出院治疗为67%）。在“灰色区”患者中，女性和男性的急性和出院治疗使用率相似，但急性阿司匹林（调整后的优势比，0.80[95%CI，0.65至0.98]）和出院时使用血管紧张素转换酶抑制剂（调整后的优势比，0.77[95%CI，0.67至0.88]）除外。“灰色区”患者的死亡率（2.3%）低于肌钙蛋白>1.5倍ULN的组（4.5%），但高于肌钙蛋白<1倍ULN的组（1.1%）。“灰色区”女性和男性的预后相似（调整后的优势比：死亡，0.88[95%CI，0.58至1.35]；死亡/心肌梗死，0.77[95%CI，0.55至1.06]；输血，1.04[95%CI，0.85至1.27]）。
非ST段抬高型急性冠状动脉综合征且肌钙蛋白轻度升高的患者总体风险较低，与肌钙蛋白升高幅度更大的患者相比，接受基于指南的积极治疗较少，但在各肌钙蛋白升高组中，不同性别的治疗模式基本相似。
