VA San Diego Healthcare System, San Diego, California; University of California, San Diego, California.
University Hospital Basel, Basel, Switzerland.
J Am Coll Cardiol. 2013 Jul 9;62(2):150-160. doi: 10.1016/j.jacc.2013.04.011. Epub 2013 Apr 30.
The goal of this study was to demonstrate that copeptin levels <14 pmol/L allow ruling out acute myocardial infarction (AMI) when used in combination with cardiac troponin I (cTnI) <99 th percentile and a nondiagnostic electrocardiogram at the time of presentation to the emergency department (ED).
Copeptin is secreted from the pituitary early in the course of AMI.
This was a 16-site study in 1,967 patients with chest pain presenting to an ED within 6 hours of pain onset. Baseline demographic characteristics and clinical data were collected prospectively. Copeptin levels and a contemporary sensitive cTnI (99 th percentile 40 ng/l; 10% coefficient of variation 0.03 μg/l) were measured in a core laboratory. Patients were followed up for 180 days. The primary outcome was diagnosis of AMI. Final diagnoses were adjudicated by 2 independent cardiologists blinded to copeptin results.
AMI was the final diagnosis in 156 patients (7.9%). A negative copeptin and cTnI at baseline ruled out AMI for 58% of patients, with a negative predictive value of 99.2% (95% confidence interval: 98.5 to 99.6). AMIs not detected by the initial cTnI alone were picked up with copeptin >14 pmol/l in 23 (72%) of 32 patients. Non-ST-segment elevation myocardial infarctions undetected by cTnI at 0 h were detected with copeptin >14 pmol/l in 10 (53%) of 19 patients. Projected average time-to-decision could be reduced by 43% (from 3.0 h to 1.8 h) by the early rule out of 58% of patients. Both abnormal copeptin and cTnI were predictors of death at 180 days (p < 0.0001 for both; c index 0.784 and 0.800, respectively). Both were independent of age and each other and provided additional predictive value (all p < 0.0001).
Adding copeptin to cTnI allowed safe rule out of AMI with a negative predictive value >99% in patients presenting with suspected acute coronary syndromes. This combination has the potential to rule out AMI in 58% of patients without serial blood draws.
本研究旨在证明，当联合检测心脏肌钙蛋白 I（cTnI）<99 百分位数和就诊时非诊断性心电图时，使用 <14 pmol/L 的 copeptin 水平可排除急性心肌梗死（AMI）。
copeptin 在 AMI 发生早期从垂体分泌。
这是一项在 1967 例胸痛患者中进行的 16 个地点的研究，这些患者在胸痛发作后 6 小时内就诊于急诊室。前瞻性收集基线人口统计学特征和临床数据。在核心实验室测量 copeptin 水平和现代敏感的 cTnI（99 百分位数 40ng/L；10%变异系数 0.03μg/L）。对患者进行 180 天的随访。主要结局是 AMI 的诊断。最终诊断由 2 位独立的、对 copeptin 结果不知情的心脏病专家盲法判定。
156 例（7.9%）患者的最终诊断为 AMI。基线时阴性的 copeptin 和 cTnI 排除了 58%的患者发生 AMI，阴性预测值为 99.2%（95%置信区间：98.5 至 99.6）。单独使用初始 cTnI 无法检测到的 AMI，通过 copeptin >14 pmol/L 在 32 例患者中的 23 例（72%）中被检出。在 19 例 0 h 时 cTnI 未能检测到的非 ST 段抬高型心肌梗死中，10 例（53%）患者的 copeptin >14 pmol/L 检测到。通过早期排除 58%的患者，平均决策时间可缩短 43%（从 3.0 小时缩短至 1.8 小时）。异常 copeptin 和 cTnI 都是 180 天死亡的预测因素（两者均为 p<0.0001；c 指数分别为 0.784 和 0.800）。两者均独立于年龄且相互独立，并提供了额外的预测价值（均为 p<0.0001）。
在疑似急性冠状动脉综合征患者中，联合检测 cTnI 和 copeptin 可安全排除 AMI，阴性预测值>99%。这种组合有可能排除 58%的患者，无需进行多次采血。
