Emergency Care Clinic Haukeland University Hospital Bergen Norway.
Department of Heart Disease Haukeland University Hospital Bergen Norway.
J Am Heart Assoc. 2020 Dec;9(23):e017465. doi: 10.1161/JAHA.120.017465. Epub 2020 Nov 26.
Background Cardiac troponin (cTn) permits early rule-out/rule-in of patients admitted with possible non-ST-segment-elevation myocardial infarction. In this study, we developed an admission and a 0/1 hour rule-out/rule-in algorithm for a troponin assay with measurable results in >99% of healthy individuals. We then compared its diagnostic and long-term prognostic properties with other protocols. Methods and Results Blood samples were collected at 0, 1, 3, and 8 to 12 hours from patients admitted with possible non-ST-segment-elevation myocardial infarction. cTnT (Roche Diagnostics), cTnI (Abbott Diagnostics), and cTnI (Singulex Clarity System) were measured in 971 admission and 465 1-hour samples. An admission and a 0/1 hour rule-out/rule-in algorithm were developed for the cTnI assay and its diagnostic properties were compared with cTnT (European Society of Cardiology), cTnI, and 2 earlier cTnI algorithms. The prognostic composite end point was all-cause mortality and future nonfatal myocardial infarction during a median follow-up of 723 days. non-ST-segment-elevation myocardial infarction prevalence was 13%. The novel cTnI algorithms showed similar performance regardless of time from symptom onset, and area under the curve was significantly better than comparators. The cTnI algorithm classified 92% of patients to rule-in or rule-out compared with ≤78% of comparators. Patients allocated to rule-out by the prior published 0/1 hour algorithms had significantly fewer long-term events compared with the rule-in and observation groups. The novel cTnI algorithm used a higher troponin baseline concentration for rule-out and did not allow for prognostication. Conclusions Increasingly sensitive troponin assays may improve identification of non-ST-segment-elevation myocardial infarction but could rule-out patients with subclinical chronic myocardial injury. Separate protocols for diagnosis and risk prediction seem appropriate.
背景 心肌肌钙蛋白（cTn）可早期排除/确诊疑似非 ST 段抬高型心肌梗死患者。本研究旨在建立一种可对 99%以上健康人群检测到结果的肌钙蛋白检测法的入院和 0/1 小时排除/确诊算法，并与其他方案比较其诊断和长期预后性能。
方法和结果 疑似非 ST 段抬高型心肌梗死患者入院后分别于 0、1、3 和 8-12 小时采集血样。入院时及 1 小时样本中检测 cTnT（罗氏诊断公司）、cTnI（雅培诊断公司）和 cTnI（Singulex Clarity 系统）。建立 cTnI 入院和 0/1 小时排除/确诊算法，并比较其诊断性能与 cTnT（欧洲心脏病学会）、cTnI 及 2 种早期 cTnI 算法。主要复合终点为全因死亡率和未来非致命性心肌梗死，中位随访 723 天。非 ST 段抬高型心肌梗死发生率为 13%。新型 cTnI 算法无论症状发作时间如何，表现均相似，曲线下面积均显著优于比较方案。与比较方案的≤78%相比，新型 cTnI 算法可将 92%的患者分类为确诊或排除。与确诊和观察组相比，根据先前发表的 0/1 小时算法归类为排除的患者长期事件发生率显著降低。新型 cTnI 算法用于排除的肌钙蛋白基础浓度较高，不允许进行预后评估。
结论 更敏感的肌钙蛋白检测可能提高非 ST 段抬高型心肌梗死的检出率，但可能会排除有亚临床慢性心肌损伤的患者。分别为诊断和风险预测制定方案可能是合适的。
