Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands.
Am J Med. 2011 Oct;124(10):961-9. doi: 10.1016/j.amjmed.2011.05.026.
Little is known about the long-term prognostic value of N-terminal pro B-type natriuretic peptide (NT-proBNP) and C-reactive protein (CRP) in low-risk patients with chest pain.
Between June 1997 and January 2000, a standard rule-out protocol was performed in patients presenting to the emergency department within 6 hours of onset of chest pain with a normal or nondiagnostic electrocardiogram (ECG) on admission at the Academic Medical Center Amsterdam, VU University Medical Center Amsterdam and Medical Center Alkmaar, The Netherlands. Patients with acute coronary syndrome were identified by troponin T, recurrent angina, and serial ECGs. CRP and NT-proBNP on admission were measured using standardized methods.
A total of 524 patients were included (145 with acute coronary syndrome and 379 with rule-out acute coronary syndrome). Long-term follow-up was successfully carried out in 96% of the study population. Death occurred in 78 patients (15%), 43 (11%) in the rule-out acute coronary syndrome group and 35 (24%) in the acute coronary syndrome group (P<.001). In the rule-out acute coronary syndrome group, 21 patients (42%) died of a cardiovascular cause compared with 24 patients (69%) in the acute coronary syndrome group (P<.001). In multivariate Cox regression analysis, age more than 65 years, previous myocardial infarction, known chronic heart failure, a nondiagnostic ECG on admission, and elevated NT-proBNP levels (>87 pg/mL, as derived from the receiver operating characteristic curve) were independent predictors of long-term cardiovascular mortality in the rule-out acute coronary syndrome group. In the acute coronary syndrome group, these predictors were age more than 65 years, documented coronary artery disease, and elevated NT-proBNP levels. Elevated levels of CRP were an independent predictor for cardiovascular mortality in patients with rule-out acute coronary syndrome at 3-year follow-up only. In patients with rule-out acute coronary syndrome with normal CRP and NT-proBNP levels, the cardiovascular mortality incidence rate was 4.7 per 1000 person-years, compared with a death rate of 20 in patients with both biomarkers elevated, which was comparable to the 17.9 per 1000 person-years incidence rate in patients with acute coronary syndrome.
A positive biomarker panel discriminates patients with rule-out acute coronary syndrome chest pain with a normal or nondiagnostic ECG who have a high risk for long-term cardiovascular mortality.
关于胸痛低危患者的 N 末端脑利钠肽前体（NT-proBNP）和 C 反应蛋白（CRP）的长期预后价值知之甚少。
1997 年 6 月至 2000 年 1 月，在荷兰阿姆斯特丹学术医学中心、阿姆斯特丹 VU 大学医学中心和阿尔克马尔医疗中心，对发病 6 小时内就诊且入院时心电图正常或无诊断价值的胸痛患者，采用标准排除方案。通过肌钙蛋白 T、复发性心绞痛和连续心电图确定急性冠状动脉综合征患者。采用标准化方法检测入院时 CRP 和 NT-proBNP。
共纳入 524 例患者（急性冠状动脉综合征 145 例，排除急性冠状动脉综合征 379 例）。96%的研究人群成功进行了长期随访。78 例患者（15%）死亡，排除急性冠状动脉综合征组 43 例（11%），急性冠状动脉综合征组 35 例（24%）（P<.001）。在排除急性冠状动脉综合征组中，21 例（42%）死于心血管原因，而急性冠状动脉综合征组中 24 例（69%）死于心血管原因（P<.001）。多变量 Cox 回归分析显示，年龄>65 岁、既往心肌梗死、已知慢性心力衰竭、入院时心电图无诊断价值以及 NT-proBNP 水平升高（>87pg/ml，来源于受试者工作特征曲线）是排除急性冠状动脉综合征组患者长期心血管死亡的独立预测因素。在急性冠状动脉综合征组中，这些预测因素是年龄>65 岁、有记录的冠状动脉疾病和 NT-proBNP 水平升高。仅在 3 年随访时，CRP 水平升高是排除急性冠状动脉综合征患者心血管死亡率的独立预测因素。在排除急性冠状动脉综合征且 CRP 和 NT-proBNP 水平正常的患者中，心血管死亡率发生率为每 1000 人年 4.7 例，而两项生物标志物均升高的死亡率为 20 例，与急性冠状动脉综合征患者每 1000 人年 17.9 例的发生率相当。
阳性生物标志物谱可区分心电图正常或无诊断价值的排除急性冠状动脉综合征胸痛患者，这些患者具有发生长期心血管死亡的高风险。
