McRae Andrew D, Innes Grant, Graham Michelle, Lang Eddy, Andruchow James E, Yang Hong, Ji Yunqi, Vatanpour Shabnam, Southern Danielle A, Wang Dongmei, Seiden-Long Isolde, DeKoning Lawrence, Kavsak Peter
Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
Can J Cardiol. 2017 Aug;33(8):1006-1012. doi: 10.1016/j.cjca.2017.04.010. Epub 2017 May 3.
Symptoms of acute coronary syndrome account for a large proportion of emergency department (ED) visits and hospitalizations. High-sensitivity troponin can rapidly rule out or rule in acute myocardial infarction (AMI) within a short time of ED arrival. We sought to validate test characteristics and classification performance of 2-hour high-sensitivity troponin T (hsTnT) algorithms for the rapid diagnosis of AMI.
We included consecutive patients from 4 academic EDs with suspected cardiac chest pain who had hsTnT assays performed 2 hours apart (± 30 minutes) as part of routine care. The primary outcome was AMI at 7 days. Secondary outcomes included major adverse cardiac events (mortality, AMI, and revascularization). Test characteristics and classification performance for multiple 2-hour algorithms were quantified.
Seven hundred twenty-two patients met inclusion criteria. Seven-day AMI incidence was 10.9% and major adverse cardiac event incidence was 13.7%. A 2-hour rule-out algorithm proposed by Reichlin and colleagues ruled out AMI in 59.4% of patients with 98.7% sensitivity and 99.8% negative predictive value (NPV). The 2-hour rule-out algorithm proposed by the United Kingdom National Institute for Health and Care Excellence ruled out AMI in 50.3% of patients with similar sensitivity and NPV. Other exploratory algorithms had similar sensitivity but marginally better classification performance. According to Reichlin et al., the 2-hour rule-in algorithm ruled in AMI in 16.5% of patients with 92.4% specificity and 58.5% positive predictive value.
Two-hour hsTnT algorithms can rule out AMI with very high sensitivity and NPV. The algorithm developed by Reichlin et al. had superior classification performance. Reichlin and colleagues' 2-hour rule-in algorithm had poor positive predictive value and might not be suitable for early rule-in decision-making.
急性冠状动脉综合征的症状在急诊科就诊和住院病例中占很大比例。高敏肌钙蛋白可在急诊科就诊后短时间内快速排除或确诊急性心肌梗死（AMI）。我们旨在验证2小时高敏肌钙蛋白T（hsTnT）算法在AMI快速诊断中的检测特征和分类性能。
我们纳入了来自4个学术急诊科的连续患者，这些患者因疑似心脏性胸痛接受了hsTnT检测，检测时间间隔为2小时（±30分钟），这是常规护理的一部分。主要结局是7天时的AMI。次要结局包括主要不良心脏事件（死亡率、AMI和血运重建）。对多种2小时算法的检测特征和分类性能进行了量化。
722例患者符合纳入标准。7天AMI发病率为10.9%，主要不良心脏事件发病率为13.7%。Reichlin及其同事提出的2小时排除算法在59.4%的患者中排除了AMI，敏感性为98.7%，阴性预测值（NPV）为99.8%。英国国家卫生与临床优化研究所提出的2小时排除算法在50.3%的患者中排除了AMI，敏感性和NPV相似。其他探索性算法具有相似的敏感性，但分类性能略好。根据Reichlin等人的研究，2小时确诊算法在16.5%的患者中确诊了AMI，特异性为92.4%，阳性预测值为58.5%。
2小时hsTnT算法可以以非常高的敏感性和NPV排除AMI。Reichlin等人开发的算法具有卓越的分类性能。Reichlin及其同事的2小时确诊算法阳性预测值较差，可能不适用于早期确诊决策。
