Department of Internal Medicine, Division of Cardiology, University Hospital, Basel, Switzerland.
Am J Med. 2011 Dec;124(12):1151-7. doi: 10.1016/j.amjmed.2011.07.032. Epub 2011 Oct 18.
Failure to identify patients with acute coronary syndrome (ACS) is a serious clinical problem. The incidence, characteristics, and outcome of ACS patients with normal high-sensitivity cardiac troponin T (hs-cTnT) levels at presentation are unknown.
In a prospective multicenter study, hs-cTnT was determined in a blinded fashion in 1181 consecutive patients presenting with acute chest pain to the emergency department. The final diagnosis of ACS was adjudicated by 2 independent cardiologists. Patients were followed for 12 months.
ACS was the adjudicated diagnosis in 351 patients (30%), including 187 patients with acute myocardial infarction (AMI) and 164 patients with unstable angina (UA). At presentation, hs-cTnT was normal (<.014 ug/L) in 112 ACS patients (32%), including 11 patients (6%) with AMI and 101 patients (62%) with UA (P <.001). Multivariable analysis revealed previous statin treatment, younger age, preserved renal function, and the absence of ST deviation on the electrocardiogram as independently associated with normal hs-cTnT levels. Mortality rates in ACS patients with normal hs-cTnT level were 0.0% at 30 days, 0.0% at 90 days, and 2.0% (95% confidence interval, 0.5-7.9) at 360 days, which was significantly lower than in ACS patients with elevated hs-cTnT level at presentation (17.5% at 360 days, P <.001). Conversely, AMI rates at 360 days was higher in ACS patients with normal versus elevated hs-cTnT levels (P=.004).
Almost one third of ACS patients have normal hs-cTnT levels at presentation, mostly patients with UA. ACS patients with normal hs-cTnT have a very low mortality, but an increased rate of AMI during the subsequent 360 days.
未能识别出急性冠状动脉综合征（ACS）患者是一个严重的临床问题。目前尚不清楚就诊时高敏心肌肌钙蛋白 T（hs-cTnT）水平正常的 ACS 患者的发生率、特征和结局。
在一项前瞻性多中心研究中，对 1181 例因急性胸痛就诊于急诊科的连续患者进行了 hs-cTnT 盲法检测。ACS 的最终诊断由 2 位独立的心脏病专家裁定。对患者进行了 12 个月的随访。
351 例患者被裁定为 ACS（30%），其中 187 例为急性心肌梗死（AMI），164 例为不稳定型心绞痛（UA）。就诊时，112 例 ACS 患者（32%）hs-cTnT 正常（<0.014ug/L），包括 11 例（6%）AMI 和 101 例（62%）UA（P<0.001）。多变量分析显示，既往他汀类药物治疗、年龄较小、肾功能正常以及心电图无 ST 段偏移与 hs-cTnT 水平正常独立相关。hs-cTnT 水平正常的 ACS 患者 30 天死亡率为 0.0%，90 天死亡率为 0.0%，360 天死亡率为 2.0%（95%置信区间，0.5-7.9），显著低于就诊时 hs-cTnT 水平升高的 ACS 患者（360 天死亡率为 17.5%，P<0.001）。相反，360 天的 AMI 发生率在 hs-cTnT 水平正常的 ACS 患者中高于 hs-cTnT 水平升高的 ACS 患者（P=0.004）。
就诊时约三分之一的 ACS 患者 hs-cTnT 水平正常，主要为 UA 患者。hs-cTnT 水平正常的 ACS 患者死亡率非常低，但在随后的 360 天内 AMI 发生率增加。
