Lee Gino, Twerenbold Raphael, Tanglay Yunus, Reichlin Tobias, Honegger Ursina, Wagener Max, Jaeger Cedric, Rubini Gimenez Maria, Hochgruber Thomas, Puelacher Christian, Radosavac Milos, Kreutzinger Philipp, Stallone Fabio, Hillinger Petra, Krivoshei Lian, Herrmann Thomas, Mayr Romy, Freese Michael, Wild Damian, Rentsch Katharina M, Todd John, Osswald Stefan, Zellweger Michael J, Mueller Christian
Department of Cardiology, University Hospital, Basel, Switzerland; Cardiovascular Research Institute Basel (CRIB), University Hospital, Basel, Switzerland.
Department of Cardiology, University Hospital, Basel, Switzerland; Cardiovascular Research Institute Basel (CRIB), University Hospital, Basel, Switzerland; Department of Internal University Hospital, Basel, Switzerland.
Am Heart J. 2016 Mar;173:8-17. doi: 10.1016/j.ahj.2015.11.010. Epub 2015 Dec 2.
A pilot study using a novel high-sensitivity cardiac troponin I (hs-cTnI) assay suggested that cTnI might be released into blood during exercise-induced myocardial ischemia. We investigated the potential clinical value of this signal.
We included 819 patients with suspected exercise-induced myocardial ischemia referred for rest/bicycle myocardial perfusion single-photon emission computed tomography. The treating cardiologist used all available clinical information to quantify clinical judgment regarding the presence of myocardial ischemia using a visual analog scale twice: prior and after stress testing. High-sensitivity cTnI measurements were obtained before, immediately after peak stress, and 2 hours after stress testing in a blinded manner. Myocardial ischemia was adjudicated using perfusion single-photon emission computed tomography and coronary angiography findings.
Exercise-induced myocardial ischemia was detected in 278 (34%) patients. High-sensitivity cTnI levels were significantly higher at all time points in patients with myocardial ischemia as compared with those without (P < .001 for all). Combining clinical judgment prior exercise testing with baseline hs-cTnI levels increased diagnostic accuracy as quantified by the area under the receiver operating characteristics curve (AUC) from 0.672 to 0.757 (P < .001). Combining clinical judgment after exercise testing (AUC 0.704) with baseline or poststress hs-cTnI levels also increased the diagnostic accuracy (AUC 0.761-0.771, P < .001 for all). In contrast, exercise-induced changes in hs-cTnI during exercise did not seem useful, as they were small and similar in patients with or without myocardial ischemia.
High-sensitivity cTnI concentrations at rest and after exercise, but not its exercise-induced changes, provide substantial incremental value to clinical judgment including exercise electrocardiography regarding the presence of myocardial ischemia.
一项使用新型高敏心肌肌钙蛋白I（hs-cTnI）检测方法的初步研究表明，在运动诱发的心肌缺血期间，cTnI可能会释放入血。我们研究了这一信号的潜在临床价值。
我们纳入了819例疑似运动诱发心肌缺血的患者，这些患者接受了静息/自行车运动心肌灌注单光子发射计算机断层扫描。主治心脏病专家利用所有可用的临床信息，使用视觉模拟量表对心肌缺血的存在进行临床判断量化，分别在运动试验前和运动试验后各进行一次。以盲法在运动高峰前、运动高峰后即刻以及运动试验后2小时测量高敏cTnI。使用灌注单光子发射计算机断层扫描和冠状动脉造影结果判定心肌缺血情况。
278例（34%）患者检测到运动诱发的心肌缺血。与未发生心肌缺血的患者相比，发生心肌缺血的患者在所有时间点的高敏cTnI水平均显著更高（所有P值均<0.001）。将运动试验前的临床判断与基线hs-cTnI水平相结合，可提高诊断准确性，通过受试者工作特征曲线下面积（AUC）量化，从0.672提高到0.757（P<0.001）。将运动试验后的临床判断（AUC 0.704）与基线或运动后hs-cTnI水平相结合，也可提高诊断准确性（AUC 0.761 - 0.771，所有P值均<0.001）。相比之下，运动期间hs-cTnI的运动诱发变化似乎没有用处，因为这些变化很小，且在有无心肌缺血的患者中相似。
静息和运动后的高敏cTnI浓度，而非其运动诱发的变化，为包括运动心电图在内的关于心肌缺血存在的临床判断提供了显著的增量价值。
