Möckel Martin
Notfall- und Akutmedizin mit Chest Pain Units, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum und Charité Mitte, Augustenburger Platz 1, 13363, Berlin, Deutschland.
Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Deutschland.
Internist (Berl). 2019 Jun;60(6):564-570. doi: 10.1007/s00108-019-0620-9.
In emergency situations, patients present with symptoms rather than diagnoses. Due to its high prevalence, the acute coronary syndrome (ACS) dominates acute diagnostics as a consequence of its chief complaint chest pain. The challenge for the attending physicians is that only a minor part of patients with chest pain are finally diagnosed with an acute myocardial infarction (AMI) and that other rare but dangerous differential diagnoses have to be kept in mind and-vice versa-severely ill patients with AMI may present with symptoms other than chest pain. Against this background, the initial evaluation of patients requires a process-orientated view beyond the key roles of clinical assessment and biomarkers. The use of cardiac troponin is mandatory for the diagnosis of ACS, but challenging in broader utilization due to the reduced clinical specificity. Further relevant biomarkers are copeptin in combination with cardiac troponin or natriuetic peptides, which help to diagnose relevant cardiac dysfunction in (acute) heart failure. In addition, patients who present with the symptom of a suspected cardiac syncope need the differential diagnosis of an underlying arrhythmia, which may be due to an ACS or reduced left ventricular (LV) function and other causes like pulmonary embolism or structural heart disease (e. g. aortic valve stenosis). This highlights that biomarker-based diagnostics are often crucial to decide after the initial clinical evaluation whether early imaging is needed or early discharge is possible.
在紧急情况下，患者表现出的是症状而非诊断结果。由于急性冠状动脉综合征（ACS）患病率高，其主要症状胸痛使其在急性诊断中占据主导地位。主治医生面临的挑战在于，最终被诊断为急性心肌梗死（AMI）的胸痛患者仅占一小部分，而且必须考虑到其他罕见但危险的鉴别诊断——反之，患有AMI的重症患者可能表现出胸痛以外的症状。在此背景下，对患者的初始评估需要一种超越临床评估和生物标志物关键作用的以流程为导向的观点。使用心肌肌钙蛋白对ACS的诊断必不可少，但由于临床特异性降低，在更广泛应用中具有挑战性。其他相关生物标志物是与心肌肌钙蛋白或利钠肽联合使用的 copeptin，其有助于诊断（急性）心力衰竭中的相关心脏功能障碍。此外，出现疑似心源性晕厥症状的患者需要对潜在心律失常进行鉴别诊断，这可能是由于ACS或左心室（LV）功能降低以及其他原因，如肺栓塞或结构性心脏病（如主动脉瓣狭窄）。这凸显了基于生物标志物的诊断对于在初始临床评估后决定是否需要早期影像学检查或是否可以早期出院通常至关重要。
