Reichlin Tobias, Schindler Christian, Drexler Beatrice, Twerenbold Raphael, Reiter Miriam, Zellweger Christa, Moehring Berit, Ziller Ronny, Hoeller Rebeca, Rubini Gimenez Maria, Haaf Philip, Potocki Mihael, Wildi Karin, Balmelli Cathrin, Freese Michael, Stelzig Claudia, Freidank Heike, Osswald Stefan, Mueller Christian
Department of Cardiology, University Hospital Basel, Switzerland.
Arch Intern Med. 2012 Sep 10;172(16):1211-8. doi: 10.1001/archinternmed.2012.3698.
High-sensitivity cardiac troponin (hs-cTn) assays seem to improve the early diagnosis of acute myocardial infarction (AMI), but it is unknown how to best use them in clinical practice. Our objective was to develop and validate an algorithm for rapid rule-out and rule-in of AMI.
A prospective multicenter study enrolling 872 unselected patients with acute chest pain presenting to the emergency department. High-sensitivity cardiac troponin T (hs-cTnT) was measured in a blinded fashion at presentation and after 1 hour. The final diagnosis was adjudicated by 2 independent cardiologists. An hs-cTnT algorithm incorporating baseline values as well as absolute changes within the first hour was derived from 436 randomly selected patients and validated in the remaining 436 patients. The primary prognostic end point was death during 30 days of follow-up.
Acute myocardial infarction was the final diagnosis in 17% of patients. After applying the hs-cTnT algorithm developed in the derivation cohort to the validation cohort, 259 patients (60%) could be classified as "rule-out," 76 patients (17%) as "rule-in," and 101 patients (23%) as in the "observational zone" within 1 hour. Overall, this resulted in a sensitivity and negative predictive value of 100% for rule-out, a specificity and positive predictive value of 97% and 84%, respectively, for rule-in, and a prevalence of AMI of 8% in the observational zone group. Cumulative 30-day survival was 99.8%, 98.6%, and 95.3% (P < .001) in patients classified as rule-out, observational zone, and rule-in, respectively.
Using a simple algorithm incorporating hs-cTnT baseline values and absolute changes within the first hour allowed a safe rule-out as well as an accurate rule-in of AMI within 1 hour in 77% of unselected patients with acute chest pain. This novel strategy may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients.
高敏心肌肌钙蛋白（hs-cTn）检测似乎能改善急性心肌梗死（AMI）的早期诊断，但尚不清楚如何在临床实践中最佳地使用它们。我们的目标是开发并验证一种用于AMI快速排除和确诊的算法。
一项前瞻性多中心研究纳入了872例未经选择的因急性胸痛就诊于急诊科的患者。在就诊时和1小时后以盲法测量高敏心肌肌钙蛋白T（hs-cTnT）。最终诊断由2名独立的心脏病专家判定。一种纳入基线值以及第1小时内绝对变化的hs-cTnT算法源自436例随机选择的患者，并在其余436例患者中进行验证。主要预后终点是随访30天内的死亡情况。
17%的患者最终诊断为急性心肌梗死。将在推导队列中开发的hs-cTnT算法应用于验证队列后，259例患者（60%）可在1小时内被分类为“排除”，76例患者（17%）为“确诊”，101例患者（23%）处于“观察区”。总体而言，这导致排除的敏感性和阴性预测值为100%，确诊的特异性和阳性预测值分别为97%和84%，观察区组中AMI的患病率为8%。在分类为排除、观察区和确诊的患者中，30天累积生存率分别为99.8%、98.6%和95.3%（P <.001）。
使用一种纳入hs-cTnT基线值和第1小时内绝对变化的简单算法，可在1小时内对77%未经选择的急性胸痛患者安全地排除AMI并准确地确诊。这种新策略可能使四分之三的患者无需进行长时间监测和系列血样采集。
