Department of Internal Medicine, University Hospital Basel, Basel, Switzerland.
Circ Heart Fail. 2012 Jan;5(1):17-24. doi: 10.1161/CIRCHEARTFAILURE.111.961243. Epub 2011 Oct 5.
The early and noninvasive differentiation of ischemic and nonischemic acute heart failure (AHF) in the emergency department (ED) is an unmet clinical need.
We quantified cardiac hemodynamic stress using B-type natriuretic peptide (BNP) and cardiomyocyte damage using 2 different cardiac troponin assays in 718 consecutive patients presenting to the ED with AHF (derivation cohort). The diagnosis of ischemic AHF was adjudicated using all information, including coronary angiography. Findings were validated in a second independent multicenter cohort (326 AHF patients). Among the 718 patients, 400 (56%) were adjudicated to have ischemic AHF. BNP levels were significantly higher in ischemic compared with nonischemic AHF (1097 [604-1525] pg/mL versus 800 [427-1317] pg/mL; P<0.001). Cardiac troponin T (cTnT) and sensitive cardiac troponin I (s-cTnI) were also significantly higher in ischemic compared with nonischemic AHF patients (0.040 [0.010-0.306] μg/L versus 0.018 [0.010-0.060] μg/L [P<0.001]; 0.024 [0.008-0.106] μg/L versus 0.016 [0.004-0.044 ] μg/L [P=0.002]). The diagnostic accuracy of BNP, cTnT, and s-cTnI for the diagnosis of ischemic AHF, as quantified by the area under the receiver-operating characteristic curve, was low (0.58 [95% CI, 0.54-0.63], 0.61 [95% CI, 0.57-0.66], and 0.59 [95% CI,0.54-0.65], respectively). These findings were confirmed in the validation cohort.
At presentation to the ED, patients with ischemic AHF exhibit more extensive hemodynamic cardiac stress and cardiomyocyte damage than patients with nonischemic AHF. However, the overlap is substantial, resulting in poor diagnostic accuracy.
在急诊科（ED）早期且无创地区分缺血性和非缺血性急性心力衰竭（AHF）是未满足的临床需求。
我们在连续 718 例因 AHF 就诊于 ED 的患者中（推导队列）使用 B 型利钠肽（BNP）量化心脏血流动力学应激，并使用 2 种不同的心脏肌钙蛋白检测方法量化心肌细胞损伤。使用包括冠状动脉造影在内的所有信息来判定缺血性 AHF 的诊断。在第二个独立的多中心队列（326 例 AHF 患者）中验证了研究结果。在 718 例患者中，有 400 例（56%）被判定为缺血性 AHF。与非缺血性 AHF 相比，缺血性 AHF 患者的 BNP 水平显著升高（1097[604-1525] pg/mL 比 800[427-1317] pg/mL；P<0.001）。与非缺血性 AHF 患者相比，心脏肌钙蛋白 T（cTnT）和敏感型心脏肌钙蛋白 I（s-cTnI）在缺血性 AHF 患者中也显著升高（0.040[0.010-0.306]μg/L 比 0.018[0.010-0.060]μg/L[P<0.001]；0.024[0.008-0.106]μg/L 比 0.016[0.004-0.044]μg/L [P=0.002]）。通过受试者工作特征曲线下面积评估，BNP、cTnT 和 s-cTnI 诊断缺血性 AHF 的诊断准确性较低（分别为 0.58[95%CI，0.54-0.63]、0.61[95%CI，0.57-0.66]和 0.59[95%CI，0.54-0.65]）。这些发现在验证队列中得到了证实。
在 ED 就诊时，与非缺血性 AHF 患者相比，缺血性 AHF 患者表现出更广泛的血流动力学心脏应激和心肌细胞损伤。然而，重叠程度很大，导致诊断准确性较差。
