高敏肌钙蛋白单独或与 copeptin 联合应用，对于入院时极早期就诊的患者，其用于排除 NSTEMI 的敏感性是否足够？一项在急诊科进行的事后分析。
Is high-sensitivity troponin, alone or in combination with copeptin, sensitive enough for ruling out NSTEMI in very early presenters at admission? A post hoc analysis performed in emergency departments.
机构信息
Service de Diagnostic Biologique Automatisé, Hôpital Cochin, Hôpitaux Universitaires Paris Centre (HUPC), Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France.
Département des Urgences, Hôpital Lapeyronie, CHU de Montpellier, Montpellier, France.
出版信息
BMJ Open. 2019 Jun 16;9(6):e023994. doi: 10.1136/bmjopen-2018-023994.
OBJECTIVES
Copeptin and high-sensitivity cardiac troponin (HS-cTn) assays improve the early detection of non-ST-segment elevation myocardial infarction (NSTEMI). Their sensitivities may, however, be reduced in very early presenters.
SETTING
We performed a post hoc analysis of three prospective studies that included patients who presented to the emergency department for chest pain onset (CPO) of less than 6 hours.
PARTICIPANTS
449 patients were included, in whom 12% had NSTEMI. CPO occurred <2 hours from ED presentation in 160, between 2 and 4 hours in 143 and >4 hours in 146 patients. The prevalence of NSTEMI was similar in all groups (9%, 13% and 12%, respectively, p=0.281).
MEASURES
Diagnostic performances of HS-cTn and copeptin at presentation were examined according to CPO. The discharge diagnosis was adjudicated by two experts, including cardiac troponin I (cTnI). HS-cTn and copeptin were blindly measured.
RESULTS
Diagnostic accuracies of cTnI, cTnI +copeptin and HS-cardiac troponin T (HS-cTnT) (but not HS-cTnT +copeptin) lower through CPO categories. For patients with CPO <2 hours, the choice of a threshold value of 14 ng/L for HS-cTnT resulted in three false negative (Sensitivity 80%(95% CI 51% to 95%); specificity 85% (95% CI 78% to 90%); 79% of correctly ruled out patients) and that of 5 ng/L in two false negative (sensitivity 87% (95% CI 59% to 98%); specificity 58% (95% CI 50% to 66%); 52% of correctly ruled out patients). The addition of copeptin to HS-cTnT induced a decrease of misclassified patients to 1 in patients with CPO <2 hours (sensitivity 93% (95% CI 66% to 100%); specificity 41% (95% CI 33% to 50%)).
CONCLUSION
A single measurement of HS-cTn, alone or in combination with copeptin at admission, seems not safe enough for ruling out NSTEMI in very early presenters (with CPO <2 hours).
TRIAL REGISTRATION NUMBER
DC-2009-1052.
目的
加压素原和高敏心肌肌钙蛋白（hs-cTn）检测可提高非 ST 段抬高型心肌梗死（NSTEMI）的早期检出率。然而，在发病极早期，其敏感度可能降低。
背景
我们对三项纳入胸痛发作（CPO）＜6 小时就诊于急诊科患者的前瞻性研究进行了事后分析。
患者
共纳入 449 例患者，其中 12%为 NSTEMI。160 例患者的 CPO 距 ED 就诊＜2 小时，143 例患者为 2～4 小时，146 例患者＞4 小时。各组间 NSTEMI 的发生率相似（分别为 9%、13%和 12%，p=0.281）。
检测方法
根据 CPO 检测 hs-cTn 和加压素原的诊断性能。通过两位专家（包括心肌肌钙蛋白 I[cTnI]）对出院诊断进行判定。hs-cTn 和加压素原的检测均为盲法。
结果
随着 CPO 时间的延长，cTnI、cTnI+加压素原和高敏肌钙蛋白 T（hs-cTnT）（但不是 hs-cTnT+加压素原）的诊断准确性逐渐降低。对于 CPO＜2 小时的患者，选择 hs-cTnT 截断值为 14ng/L 时，有 3 例漏诊（敏感度 80%（95%CI 51%～95%）；特异度 85%（95%CI 78%～90%）；79%的排除患者正确），截断值为 5ng/L 时有 2 例漏诊（敏感度 87%（95%CI 59%～98%）；特异度 58%（95%CI 50%～66%）；52%的排除患者正确）。hs-cTnT 联合加压素原检测可将 CPO＜2 小时患者的误诊患者数减少至 1 例（敏感度 93%（95%CI 66%～100%）；特异度 41%（95%CI 33%～50%））。
结论
入院时单独检测 hs-cTn 或联合检测加压素原，似乎不能为发病极早期（CPO＜2 小时）患者排除 NSTEMI 提供足够的保障。
试验注册
DC-2009-1052。
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