Weir Robin A P, Osmanska Joanna, Docherty Kieran F, Petrie Colin J
Cardiology Department, University Hospital Hairmyres, Lanarkshire, Scotland.
Cardiology Department, Golden Jubilee National Hospital, Glasgow, Scotland.
Acta Cardiol. 2020 Apr;75(2):149-155. doi: 10.1080/00015385.2018.1561598. Epub 2019 Jan 16.
Patients with chest pain are risk-stratified using serial high-sensitivity troponin (T) assays (hsTnT). Those with change in (Δ)hsTnT <20% are often categorised as low-risk and are less likely to be managed as acute coronary syndromes (ACS). We sought to characterise such a population of 'low-risk' chest pain presenters. We performed a retrospective cohort analysis of sequential patients admitted to our centre over a 1-year period with chest pain, absence of ST-elevation, with elevated hsTnT concentrations, and compared demographic, clinical and outcome data according to ΔhsTnT. Three hundred and eleven patients were subdivided by ΔhsTnT [<20% ( = 80), 20-100% ( = 78), >100% ( = 153)]. Baseline demographic data were well-matched across the three subgroups; atrial fibrillation was more common in the two lower magnitude ΔhsTnT groups. Obstructive coronary artery disease (CAD) - while less common in those with ΔhsTnT <20% (66.2%) compared to the 20-100% (73.1%) and >100% (75.9%) groups ( = 0.03) - remained high in this lower risk group, and indeed revascularisation occurred in >60% of patients, equally frequently in all three groups. Using absolute ΔhsTnT ≥9ng/L within the ΔhsTnT <20% group provided incremental value in ruling in ACS, with a positive predictive value of 74.1%. ΔhsTnT was a univariate but not a multivariate predictor of obstructive CAD. Obstructive CAD and need for revascularisation are frequent in chest pain presenters with ΔhsTnT <20%. The increasing focus on hsTnT algorithms to exclude ACS and promote early discharge without adequate clinical risk stratification modelling risks misdiagnosis of patients presenting with acute myocardial ischaemia with a low-level hsTnT rise.
使用连续高敏肌钙蛋白（T）检测（hsTnT）对胸痛患者进行危险分层。hsTnT变化（Δ）<20%的患者通常被归类为低风险，不太可能按照急性冠状动脉综合征（ACS）进行管理。我们试图对这类“低风险”胸痛患者群体进行特征描述。我们对在1年期间因胸痛、无ST段抬高、hsTnT浓度升高而入住我们中心的连续患者进行了回顾性队列分析，并根据ΔhsTnT比较了人口统计学、临床和结局数据。311例患者按ΔhsTnT[<20%（n = 80）、20 - 100%（n = 78）、>100%（n = 153）]进行细分。三个亚组的基线人口统计学数据匹配良好；房颤在两个ΔhsTnT变化幅度较小的组中更常见。阻塞性冠状动脉疾病（CAD）——与ΔhsTnT为20 - 100%（73.1%）和>100%（75.9%）的组相比，在ΔhsTnT<20%的患者中不太常见（66.2%）（P = 0.03）——在这个低风险组中仍然很高，实际上超过60%的患者进行了血运重建，在所有三个组中频率相同。在ΔhsTnT<20%的组中使用绝对ΔhsTnT≥9ng/L在诊断ACS方面提供了额外价值，阳性预测值为74.1%。ΔhsTnT是阻塞性CAD的单因素而非多因素预测指标。在ΔhsTnT<20%的胸痛患者中，阻塞性CAD和血运重建需求很常见。越来越关注hsTnT算法以排除ACS并促进早期出院，但没有充分的临床风险分层模型，这有对hsTnT升高水平较低的急性心肌缺血患者误诊的风险。
