心肌肌钙蛋白轻度升高患者急性心肌梗死的早期诊断
Early diagnosis of acute myocardial infarction in patients with mild elevations of cardiac troponin.
作者信息
Boeddinghaus Jasper, Reichlin Tobias, Nestelberger Thomas, Twerenbold Raphael, Meili Yvette, Wildi Karin, Hillinger Petra, Giménez Maria Rubini, Cupa Janosch, Schumacher Lukas, Schubera Marie, Badertscher Patrick, Corbière Sydney, Grimm Karin, Puelacher Christian, Sabti Zaid, Widmer Dayana Flores, Schaerli Nicolas, Kozhuharov Nikola, Shrestha Samyut, Bürge Tobias, Mächler Patrick, Büchi Michael, Rentsch Katharina, Miró Òscar, López Beatriz, Martin-Sanchez F Javier, Rodriguez-Adrada Esther, Morawiec Beata, Kawecki Damian, Ganovská Eva, Parenica Jiri, Lohrmann Jens, Buser Andreas, Keller Dagmar I, Osswald Stefan, Mueller Christian
机构信息
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland.
出版信息
Clin Res Cardiol. 2017 Jun;106(6):457-467. doi: 10.1007/s00392-016-1075-9. Epub 2017 Feb 1.
BACKGROUND
The early diagnosis of acute myocardial infarction (AMI) in patients with mild elevations of high-sensitivity cardiac troponin (hs-cTn) is a challenge. It is unclear whether copeptin, a marker of endogenous stress, or 1h-hs-cTn changes are better suited to address this important unmet clinical need.
METHODS
We prospectively enrolled patients presenting with symptoms suggestive of AMI to the emergency department (ED). Two independent cardiologists adjudicated the final diagnosis. Mild hs-cTn elevations were defined as 26.2 ng/L (99th percentile) to 75 ng/L for hs-cTnI, and 14 ng/L (99th percentile) to 50 ng/L (biological-equivalent to 75 ng/L for hs-cTnI) for hs-cTnT.
RESULTS
Among 1356 patients, 80 (6%) had mild hs-cTnI elevations at presentation. Within this group, AMI was the final diagnosis in 39 patients (49%). The diagnostic accuracy for the diagnosis of AMI as quantified by the area under the receiver operating characteristic curve (AUC) was 0.51 (95% CI 0.39-0.64) for hs-cTnI at presentation, 0.58 (95% CI 0.45-0.71) for copeptin at presentation, and 0.78 (95% CI 0.68-0.88) for 1h-hs-cTnI changes, which was significantly higher as compared to copeptin (p = 0.02) or hs-cTnI alone (p < 0.001). The additional use of 1h-hs-cTnI changes, but not of copeptin, improved diagnostic accuracy of hs-cTnI at presentation (AUC 0.80, 95% CI 0.70-0.90; p = 0.002 for comparison). Similar findings regarding copeptin and 1h-hs-cTnT/I changes were obtained for mild hs-cTnT elevations.
CONCLUSIONS
About 6-22% of patients presenting with suggestive AMI to the ED have mild hs-cTnT/I elevations at presentation. In contrast to copeptin, the addition of 1h-hs-cTn changes substantially improves the early diagnosis of AMI.
背景
对于高敏心肌肌钙蛋白（hs-cTn）轻度升高的患者，急性心肌梗死（AMI）的早期诊断具有挑战性。目前尚不清楚内源性应激标志物 copeptin 或 1 小时 hs-cTn 变化是否更适合满足这一尚未满足的重要临床需求。
方法
我们前瞻性纳入了因出现提示 AMI 的症状而到急诊科（ED）就诊的患者。由两名独立的心脏病专家判定最终诊断结果。轻度 hs-cTn 升高定义为 hs-cTnI 为 26.2 ng/L（第 99 百分位数）至 75 ng/L，hs-cTnT 为 14 ng/L（第 99 百分位数）至 50 ng/L（与 hs-cTnI 的 75 ng/L 生物学等效）。
结果
在 1356 例患者中，80 例（6%）就诊时 hs-cTnI 轻度升高。在该组中，39 例（49%）最终诊断为 AMI。就诊时 hs-cTnI 诊断 AMI 的诊断准确性，通过受试者操作特征曲线下面积（AUC）量化为 0.51（95%CI 0.39 - 0.64），就诊时 copeptin 为 0.58（95%CI 0.45 - 0.71），1 小时 hs-cTnI 变化为 0.78（95%CI 0.68 - 0.88），1 小时 hs-cTnI 变化显著高于 copeptin（p = 0.02）或单独的 hs-cTnI（p < 0.001）。1 小时 hs-cTnI 变化的额外应用而非 copeptin 的应用，提高了就诊时 hs-cTnI 的诊断准确性（AUC 0.80，95%CI 0.70 - 0.90；比较 p = 0.002）。对于轻度 hs-cTnT 升高，在 copeptin 和 1 小时 hs-cTnT/I 变化方面也获得了类似的结果。
结论
因提示 AMI 到 ED 就诊的患者中，约 6% - 22%就诊时 hs-cTnT/I 轻度升高。与 copeptin 不同，1 小时 hs-cTn 变化的加入显著改善了 AMI 的早期诊断。
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