From the University Heart Center Hamburg (J.T.N., R.T., F.O., N.A.S., T.Z., D.W., S.B.), German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (J.T.N., N.A.S., T.Z., D.W., S.B.), and the Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf (T.R.), Hamburg, the Department of Cardiology, Heidelberg University Hospital (M.M.-H., H.A.K., E.G.), and DZHK Partner Site Heidelberg-Mannheim (M.M.-H., H.A.K., E.G.), Heidelberg, Cardiology I (T.G., T.M.) and Preventive Cardiology and Preventive Medicine (P.W.), Center for Cardiology, and the Center for Thrombosis and Hemostasis (P.W.), University Medical Center of Johannes Gutenberg University Mainz, and the Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz (K.J.L.), Mainz, DZHK Partner Site Rhine-Main and the Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim (C.L., C.H., T.K.), the Department of Cardiology, Justus Liebig University of Giessen and Marburg, Giessen (C.L., C.H.), the Department of Cardiology, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin Institute of Health, and DZHK Partner Site Berlin, Berlin (U.L.), and the Institute of Epidemiology, Helmholtz Zentrum, German Research Center for Environmental Health (B.T., A.P.), and DZHK Partner Site Munich Heart Alliance (A.P.), Munich - all in Germany; the Cardiovascular Research Institute Basel and the Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (R.T., J.B., T.N., P.B., C.M.); the British Heart Foundation Centre for Cardiovascular Science (A.R.C., A.S.V.S., A.A., N.L.M.) and the Usher Institute of Population Health Sciences and Informatics (A.S.V.S., N.L.M.), University of Edinburgh, Edinburgh, the University of Manchester and Manchester University Foundation Trust, Manchester (N.M., R. Body), U.K. Clinical Research Collaboration for Public Health, Queens University of Belfast, Belfast (F.K.), and the Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Dundee (H.T.-P.) - all in the United Kingdom; the Department of Internal and Emergency Medicine, Lund University, Skåne University Hospital, Lund (A.M., U.E.), the Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm (T. Jernberg), the Department of Public Health and Clinical Medicine, and Heart Center, Cardiology, Umeå University, Umeå (S. Söderberg), and the Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala (B.L.) - all in Sweden; the Department of Medicine, University of Otago Christchurch, and Emergency Department, Christchurch Hospital, Christchurch, New Zealand (J.W.P., R.W.T., M.T.); the Departments of Emergency Medicine (J.G., L.A.C.) and Cardiology (W.P.), Royal Brisbane and Women's Hospital, Herston, QLD, and the Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove (J.G., W.P., L.A.C.) - all in Australia; the National Institute for Health and Welfare, Helsinki, Finland (V.S., K.K.); the Department of Epidemiology and Prevention, Istituto di Ricovero e Cura a Carattere Scientifico Neuromed, Pozzilli (L.I.), the Department of Medicine and Surgery, Research Center in Epidemiology and Preventive Medicine, University of Insubria, Varese (L.I., M.M.F., R. Borchini), and the Department of Cardiovascular, Dysmetabolic, and Aging-Associated Diseases, National Institutes of Health, Rome (S.G.) - all in Italy; the Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen (T. Jørgensen), the Research Center for Prevention and Health, Capital Region of Denmark, Glostrup (T. Jørgensen), and the Medical Faculty, Aalborg University, Aalborg (T. Jørgensen) - all in Denmark; the Catalan Department of Health, Barcelona (S. Sans); and the Division of Emergency Medicine (A.W.) and the Department of Pathology and Molecular Medicine (P.A.K.), McMaster University, Hamilton, ON, Canada.
N Engl J Med. 2019 Jun 27;380(26):2529-2540. doi: 10.1056/NEJMoa1803377.
Data regarding high-sensitivity troponin concentrations in patients presenting to the emergency department with symptoms suggestive of myocardial infarction may be useful in determining the probability of myocardial infarction and subsequent 30-day outcomes.
In 15 international cohorts of patients presenting to the emergency department with symptoms suggestive of myocardial infarction, we determined the concentrations of high-sensitivity troponin I or high-sensitivity troponin T at presentation and after early or late serial sampling. The diagnostic and prognostic performance of multiple high-sensitivity troponin cutoff combinations was assessed with the use of a derivation-validation design. A risk-assessment tool that was based on these data was developed to estimate the risk of index myocardial infarction and of subsequent myocardial infarction or death at 30 days.
Among 22,651 patients (9604 in the derivation data set and 13,047 in the validation data set), the prevalence of myocardial infarction was 15.3%. Lower high-sensitivity troponin concentrations at presentation and smaller absolute changes during serial sampling were associated with a lower likelihood of myocardial infarction and a lower short-term risk of cardiovascular events. For example, high-sensitivity troponin I concentrations of less than 6 ng per liter and an absolute change of less than 4 ng per liter after 45 to 120 minutes (early serial sampling) resulted in a negative predictive value of 99.5% for myocardial infarction, with an associated 30-day risk of subsequent myocardial infarction or death of 0.2%; a total of 56.5% of the patients would be classified as being at low risk. These findings were confirmed in an external validation data set.
A risk-assessment tool, which we developed to integrate the high-sensitivity troponin I or troponin T concentration at emergency department presentation, its dynamic change during serial sampling, and the time between the obtaining of samples, was used to estimate the probability of myocardial infarction on emergency department presentation and 30-day outcomes. (Funded by the German Center for Cardiovascular Research [DZHK]; ClinicalTrials.gov numbers, NCT00470587, NCT02355457, NCT01852123, NCT01994577, and NCT03227159; and Australian New Zealand Clinical Trials Registry numbers, ACTRN12611001069943, ACTRN12610000766011, ACTRN12613000745741, and ACTRN12611000206921.).
在因疑似心肌梗死而到急诊科就诊的患者中，有关高敏肌钙蛋白浓度的数据可能有助于确定心肌梗死的概率和随后 30 天的结局。
在因疑似心肌梗死而到急诊科就诊的 15 个国际队列中，我们测定了患者就诊时以及早期或晚期连续采样后的高敏肌钙蛋白 I 或高敏肌钙蛋白 T 浓度。使用推导-验证设计评估了多种高敏肌钙蛋白截断组合的诊断和预后性能。基于这些数据开发了一种风险评估工具，用于估计指数性心肌梗死以及随后 30 天内心肌梗死或死亡的风险。
在 22651 例患者中（推导数据集 9604 例，验证数据集 13047 例），心肌梗死的患病率为 15.3%。就诊时较低的高敏肌钙蛋白浓度和连续采样期间绝对值的较小变化与心肌梗死的可能性降低以及短期心血管事件风险降低相关。例如，高敏肌钙蛋白 I 浓度＜6ng/L 且 45~120 分钟（早期连续采样）时的绝对变化＜4ng/L 时，心肌梗死的阴性预测值为 99.5%，其 30 天内随后发生心肌梗死或死亡的风险为 0.2%；总计 56.5%的患者将被归类为低风险。这些发现得到了外部验证数据集的证实。
我们开发了一种风险评估工具，用于整合急诊科就诊时高敏肌钙蛋白 I 或肌钙蛋白 T 浓度、连续采样过程中的动态变化以及样本采集时间，以估计急诊科就诊时心肌梗死的概率和 30 天的结局。（由德国心血管研究中心 [DZHK] 资助；ClinicalTrials.gov 编号：NCT00470587、NCT02355457、NCT01852123、NCT01994577 和 NCT03227159；澳大利亚和新西兰临床试验注册中心编号：ACTRN12611001069943、ACTRN12610000766011、ACTRN12613000745741 和 ACTRN12611000206921）。
