Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
Am Heart J. 2012 Jun;163(6):972-979.e1. doi: 10.1016/j.ahj.2012.03.010. Epub 2012 May 21.
Compared to troponin alone, a dual-marker strategy with natriuretic peptides may improve acute coronary syndrome (ACS) diagnosis with a single blood draw and provide physiologic information regarding underlying heart disease. We evaluate the value of adding natriuretic peptides (myocyte stress markers) to troponins (myocardial injury markers) for diagnosing ACS in emergency department patients with chest pain.
In 328 patients (53 ± 12 years, 63% men) with an initially negative conventional troponin and nonischemic electrocardiogram who underwent 64-slice cardiac computed tomography (CT), we measured conventional troponin-T (cTnT), high-sensitivity troponin-T (hsTnT), N-terminal pro-B type natriuretic peptide, and mid-regional pro-atrial natriuretic peptide. ACS was defined as myocardial infarction or unstable angina. CT was evaluated for coronary plaque, stenosis, and regional wall motion abnormality.
Patients with ACS (n = 29, 9%) had higher concentrations of each biomarker compared to those without (all P < .01). Adding natriuretic peptides, especially N-terminal pro-B type natriuretic peptide, to both cTnT or hsTnT improved the C-statistics and net reclassification index for ACS, largely driven by correctly reclassifying events. Dual-negative marker results improved sensitivity (cTnT 38% to 83%-86%, hsTnT 59% to 86%-90%; all P < .01) and negative predictive value (cTnT 94% to 97%-98%, hsTnT 96% to 97%-98%) for ACS. Patients with dual-negative markers had the lowest percentage of CT coronary plaque, stenosis, and regional wall motion abnormality (all P-trend <.001).
Among emergency department patients with low-intermediate likelihood of ACS, combining natriuretic peptides with either conventional or highly-sensitive troponin improved discriminatory capacity and allowed for better reclassification of ACS, findings supported by structural and functional CT results.
与单独使用肌钙蛋白相比，双标志物策略联合利钠肽可能通过单次采血提高急性冠状动脉综合征（ACS）的诊断率，并提供有关潜在心脏病的生理信息。我们评估了在急诊科胸痛患者中，将利钠肽（心肌应激标志物）添加到肌钙蛋白（心肌损伤标志物）中用于诊断 ACS 的价值。
在 328 名（53 ± 12 岁，63%为男性）最初常规肌钙蛋白和非缺血性心电图阴性且接受 64 排 CT 检查的患者中，我们测量了常规肌钙蛋白-T（cTnT）、高敏肌钙蛋白-T（hsTnT）、N 末端 pro-B 型利钠肽和中段 pro-心房利钠肽。ACS 的定义为心肌梗死或不稳定型心绞痛。CT 用于评估冠状动脉斑块、狭窄和局部壁运动异常。
ACS 患者（n = 29，9%）的每种生物标志物浓度均高于非 ACS 患者（均 P <.01）。将利钠肽，尤其是 N 末端 pro-B 型利钠肽，添加到 cTnT 或 hsTnT 中，可提高 ACS 的 C 统计量和净重新分类指数，主要是通过正确地重新分类事件。双阴性标志物结果提高了 ACS 的敏感性（cTnT 从 38%提高至 83%-86%，hsTnT 从 59%提高至 86%-90%；均 P <.01）和阴性预测值（cTnT 从 94%提高至 97%-98%，hsTnT 从 96%提高至 97%-98%）。双阴性标志物患者的 CT 冠状动脉斑块、狭窄和局部壁运动异常的百分比最低（均 P 趋势<.001）。
在急诊科 ACS 低-中度可能性的患者中，将利钠肽与常规或高敏肌钙蛋白联合使用可提高鉴别能力，并允许更好地重新分类 ACS，这些发现得到了结构和功能 CT 结果的支持。
