Vorlat Anne, Van Hoof Viviane O, Hammami Rania, van Kerckhoven Stephanie, Van der Heijden Catharina M, Coenen Dries, Bosmans Johan M, Haine Steven, Vandendriessche Tom R, Vrints Christiaan J, Claeys Marc J
Department of Cardiology, Antwerp University Hospital, Edegem, Belgium.
Department of Clinical Chemistry, Antwerp University Hospital, Edegem, Belgium; Translational Pathophysiological Research Group, University of Antwerp, Edegem, Belgium.
Am J Cardiol. 2015 Jun 15;115(12):1667-71. doi: 10.1016/j.amjcard.2015.03.012. Epub 2015 Mar 23.
Protocols to minimize the time between 2 measurements of troponin or a combination with copeptin have been developed to rapidly rule-in or rule-out myocardial injury (MI) in patients with chest pain. These fast track protocols to rule-in and rule-out MI are not sufficiently validated for early chest pain presenters. The "early presenter" model was tested in 107 stable patients after a short period of myocardial ischemia, induced by stenting of a significant coronary artery stenosis. High-sensitivity troponin T (hsTnT), high-sensitivity troponin I (hsTnI), and copeptin were measured at the start and 90, 180, and 360 minutes after stent implantation. MI was defined as a troponin level more than the upper limit of normal (ULN) and an absolute increase of >50% ULN on the 360-minute sample. A single combined measurement of troponin and copeptin 90 minutes after the onset of ischemia has a low diagnostic value. This increases when serial measurements with 90-minute intervals are included. For ruling in MI, the highest positive predictive value (with a 95% confidence interval [CI]) can be obtained when focusing only on the increase in troponin level, with a positive predictive value of 86% (70, 93) and 80% (67, 90) for hsTnT and hsTnI, respectively. For ruling out MI, a combined absence of any troponin more than the ULN and any significant increase in troponin level perform best with a negative predictive value of 75% (55, 89) and 75% (55, 89) for hsTnT and hsTnI, respectively. In conclusion, in early presenters, rapid biomarker protocols underestimate MI. A standard biomarker assessment after 3 hours is required to adequately rule-in or rule-out myonecrosis.
已制定方案以尽量缩短肌钙蛋白两次测量之间的时间，或与 copeptin 联合使用，以便在胸痛患者中快速排除或确诊心肌损伤（MI）。这些用于排除和确诊 MI 的快速通道方案尚未在早期胸痛患者中得到充分验证。在 107 例稳定患者中，通过对严重冠状动脉狭窄进行支架置入术诱导短暂心肌缺血后，对“早期患者”模型进行了测试。在支架植入开始时以及植入后 90、180 和 360 分钟测量高敏肌钙蛋白 T（hsTnT）、高敏肌钙蛋白 I（hsTnI）和 copeptin。MI 的定义为肌钙蛋白水平超过正常上限（ULN），且在 360 分钟样本中绝对增加>50%ULN。缺血发作 90 分钟后单次联合测量肌钙蛋白和 copeptin 的诊断价值较低。当包括每隔 90 分钟进行的系列测量时，诊断价值会增加。对于确诊 MI，仅关注肌钙蛋白水平的升高时可获得最高的阳性预测值（95%置信区间[CI]），hsTnT 和 hsTnI 的阳性预测值分别为 86%（70，93）和 80%（67，90）。对于排除 MI，肌钙蛋白均未超过 ULN且肌钙蛋白水平无任何显著升高的联合情况表现最佳，hsTnT 和 hsTnI 的阴性预测值分别为 75%（55，89）和 75%（55，89）。总之，在早期患者中，快速生物标志物方案会低估 MI。需要在 3 小时后进行标准生物标志物评估，以充分排除或确诊心肌坏死。
