年龄对 ESC 0/1h 算法早期诊断心肌梗死性能的影响。
Impact of age on the performance of the ESC 0/1h-algorithms for early diagnosis of myocardial infarction.
机构信息
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland.
Division of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland.
出版信息
Eur Heart J. 2018 Nov 7;39(42):3780-3794. doi: 10.1093/eurheartj/ehy514.
AIMS
We aimed to evaluate the impact of age on the performance of the European Society of Cardiology (ESC) 0/1h-algorithms and to derive and externally validate alternative cut-offs specific to older patients.
METHODS AND RESULTS
We prospectively enrolled patients presenting to the emergency department (ED) with symptoms suggestive of acute myocardial infarction in three large diagnostic studies. Final diagnoses were adjudicated by two independent cardiologists. High-sensitivity cardiac troponin (hs-cTn) T and I concentrations were measured at presentation and after 1 h. Patients were stratified according to age [<55 years (young), ≥55 to <70 years (middle-age), ≥70 years (old)]. Rule-out safety of the ESC hs-cTnT 0/1h-algorithm was very high in all age-strata: sensitivity 100% [95% confidence interval (95% CI) 94.9-100] in young, 99.3% (95% CI 96.0-99.9) in middle-age, and 99.3% (95% CI 97.5-99.8) in old patients. Accuracy of rule-in decreased with age: specificity 97.0% (95% CI 95.8-97.9) in young, 96.1% (95% CI 94.5-97.2) in middle-age, and 92.7% (95% CI 90.7-94.3) in older patients. Triage efficacy decreased with increasing age (young 93%, middle-age 80%, old 55%, P < 0.001). Similar results were found for the ESC hs-cTnT 0/1h-algorithm. Alternative, slightly higher cut-off concentrations optimized for older patients maintained very high safety of rule-out, increased specificity of rule-in (P < 0.01), reduced overall efficacy for hs-cTnT (P < 0.01), while maintaining efficacy for hs-cTnI. Findings were confirmed in two validation cohorts (n = 2767).
CONCLUSION
While safety of the ESC 0/1h-algorithms remained very high, increasing age significantly reduced overall efficacy and the accuracy of rule-in. Alternative slightly higher cut-off concentrations may be considered for older patients, particularly if using hs-cTnI.
CLINICAL TRIAL REGISTRATION
https://clinicaltrials.gov/ct2/show/NCT00470587, number NCT00470587 and NCT02355457 (BACC).
目的
我们旨在评估年龄对欧洲心脏病学会（ESC）0/1h 算法性能的影响，并推导出适用于老年患者的替代截断值并进行外部验证。
方法和结果
我们前瞻性地纳入了在三个大型诊断研究中因疑似急性心肌梗死而就诊于急诊科的患者。最终诊断由两名独立的心脏病专家进行裁决。在就诊时和 1 小时后测量高敏肌钙蛋白（hs-cTn）T 和 I 浓度。根据年龄[<55 岁（年轻），≥55 岁至<70 岁（中年），≥70 岁（老年）]对患者进行分层。ESC hs-cTnT 0/1h 算法在所有年龄组中的排除安全性都非常高：在年轻患者中，敏感性为 100%（95%置信区间 [95%CI] 94.9-100），在中年患者中为 99.3%（95%CI 96.0-99.9），在老年患者中为 99.3%（95%CI 97.5-99.8）。随着年龄的增长，规则纳入的准确性降低：在年轻患者中，特异性为 97.0%（95%CI 95.8-97.9），在中年患者中为 96.1%（95%CI 94.5-97.2），在老年患者中为 92.7%（95%CI 90.7-94.3）。随着年龄的增长，分诊效果降低（年轻患者 93%，中年患者 80%，老年患者 55%，P<0.001）。ESC hs-cTnT 0/1h 算法也得到了类似的结果。针对老年患者优化的替代、略高的截断值，仍然保持了非常高的排除安全性，提高了规则纳入的特异性（P<0.01），降低了 hs-cTnT 的总体疗效（P<0.01），同时保持了 hs-cTnI 的疗效。在另外两个验证队列（n=2767）中证实了这些发现。
结论
尽管 ESC 0/1h 算法的安全性仍然非常高，但随着年龄的增长，整体疗效和规则纳入的准确性显著降低。针对老年患者，可能需要考虑替代的略高截断值，特别是在使用 hs-cTnI 时。
临床试验注册
https://clinicaltrials.gov/ct2/show/NCT00470587，注册号 NCT00470587 和 NCT02355457（BACC）。
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