Department of Emergency Medicine, William Beaumont Hospital-Royal Oak, Royal Oak, MI.
Department of Biostatistics, University of California Los Angeles, Fielding School of Public Health, Los Angeles, CA.
Acad Emerg Med. 2019 May;26(5):528-538. doi: 10.1111/acem.13709. Epub 2019 Mar 4.
An estimated 1.2 million annual emergency department (ED) visits for syncope/near syncope occur in the United States. Cardiac biomarkers are frequently obtained during the ED evaluation, but the prognostic value of index high-sensitivity troponin (hscTnT) and natriuretic peptide (NT-proBNP) are unclear. The objective of this study was to determine if hscTnT and NT-proBNP drawn in the ED are independently associated with 30-day death/serious cardiac outcomes in adult patients presenting with syncope.
A prespecified secondary analysis of a prospective, observational trial enrolling participants ≥ age 60 presenting with syncope, at 11 United States hospitals, was conducted between April 2013 and September 2016. Exclusions included seizure, stroke, transient ischemic attack, trauma, intoxication, hypoglycemia, persistent confusion, mechanical/electrical invention, prior enrollment, or predicted poor follow-up. Within 3 hours of consent, hscTnT and NT-proBNP were collected and later analyzed centrally using Roche Elecsys Gen 5 STAT and 2010 Cobas, respectively. Primary outcome was combined 30-day all-cause mortality and serious cardiac events. Adjusting for illness severity, using multivariate logistic regression analysis, variations between primary outcome and biomarkers were estimated, adjusting absolute risk associated with ranges of biomarkers using Bayesian Markov Chain Monte Carlo methods.
The cohort included 3,392 patients; 367 (10.8%) experienced the primary outcome. Adjusted absolute risk for the primary outcome increased with hscTnT and NT-proBNP levels. HscTnT levels ≤ 5 ng/L were associated with a 4% (95% confidence interval [CI] = 3%-5%) outcome risk, and hscTnT > 50 ng/L, a 29% (95% CI = 26%-33%) risk. NT-proBNP levels ≤ 125 ng/L were associated with a 4% (95% CI = 4%-5%) risk, and NT-proBNP > 2,000 ng/L a 29% (95% CI = 25%-32%) risk. Likelihood ratios and predictive values demonstrated similar results. Sensitivity analyses excluding ED index serious outcomes demonstrated similar findings.
hscTnT and NT-proBNP are independent predictors of 30-day death and serious outcomes in older ED patients presenting with syncope.
在美国，每年约有 120 万例因晕厥/近乎晕厥而到急诊科（ED）就诊。在 ED 评估期间经常会获得心脏生物标志物，但高敏肌钙蛋白（hscTnT）和利钠肽（NT-proBNP）的预后价值尚不清楚。本研究的目的是确定 ED 中抽取的 hscTnT 和 NT-proBNP 是否与成年晕厥患者 30 天内死亡/严重心脏结局独立相关。
对 2013 年 4 月至 2016 年 9 月期间在 11 家美国医院进行的前瞻性观察性试验的预先指定的次要分析进行了研究。排除标准包括癫痫发作、中风、短暂性脑缺血发作、创伤、中毒、低血糖、持续意识不清、机械/电发明、先前入组或预计预后不佳。在同意后 3 小时内，采集 hscTnT 和 NT-proBNP，并使用罗氏 Elecsys Gen 5 STAT 和 2010 Cobas 分别进行中心分析。主要结局是联合 30 天全因死亡率和严重心脏事件。使用多变量逻辑回归分析，根据疾病严重程度调整，估计主要结局和生物标志物之间的差异，使用贝叶斯马尔可夫链蒙特卡罗方法调整与生物标志物范围相关的绝对风险。
该队列纳入了 3392 例患者；367 例（10.8%）发生了主要结局。随着 hscTnT 和 NT-proBNP 水平的升高，调整后的主要结局的绝对风险增加。hscTnT 水平≤5ng/L 与 4%（95%置信区间[CI]为 3%-5%）的结局风险相关，hscTnT>50ng/L 与 29%（95% CI = 26%-33%）的风险相关。NT-proBNP 水平≤125ng/L 与 4%（95% CI = 4%-5%）的风险相关，NT-proBNP>2000ng/L 与 29%（95% CI = 25%-32%）的风险相关。似然比和预测值显示出相似的结果。排除 ED 指数严重结局的敏感性分析得出了相似的结果。
hscTnT 和 NT-proBNP 是老年 ED 患者晕厥时 30 天内死亡和严重结局的独立预测因素。
