在初级保健急诊环境中，单次高敏心肌肌钙蛋白 T 测定与 HEART 评分用于快速排除急性心肌梗死的比较：一项队列研究。
Comparison of a single high-sensitivity cardiac troponin T measurement with the HEART score for rapid rule-out of acute myocardial infarction in a primary care emergency setting: a cohort study.
机构信息
Department of General Practice, University of Oslo, Oslo, Norway
Department of Emergency General Practice, Oslo Accident and Emergency Outpatient Clinic, Oslo, Norway.
出版信息
BMJ Open. 2021 Feb 24;11(2):e046024. doi: 10.1136/bmjopen-2020-046024.
OBJECTIVE
This study aims to compare the rule-out safety of a single high-sensitivity cardiac troponin T (hs-cTnT) with the History, ECG, Age, Risk factors and Troponin (HEART) score in a low-prevalence primary care setting of acute myocardial infarction (AMI).
PARTICIPANTS
Patients with non-specific symptoms suggestive of AMI were consecutively enroled at a primary care emergency clinic in Oslo, Norway from November 2016 to October 2018.
METHODS
After initial assessment by a general practitioner, hs-cTnT samples were drawn. AMI was ruled-out by a single hs-cTnT <5 ng/L measured ≥3 hours after symptom onset. The HEART score was calculated retrospectively; a score ≤3 of 10 points was considered low risk. We also calculated a modified HEART score using more sensitive hs-cTnT thresholds. The primary outcome was the diagnostic performance for the rule-out of AMI at the index event; the secondary the composite of AMI or all-cause death at 90 days.
RESULTS
Among 1711 patients, 61 (3.6%) were diagnosed with AMI, and 569 (33.3%) patients were assigned to single rule-out (<5 ng/L). With no AMIs in this group, the negative predictive value (NPV) and sensitivity were both 100.0% (95% CI 99.4% to 100.0% and 94.1% to 100.0%, respectively), and the specificity 34.5% (32.2% to 36.8%). The original HEART score triaged more patients as low risk (n=871), but missed five AMIs (NPV 99.4% (98.7% to 99.8%); sensitivity 91.8% (81.9% to 97.3%) and specificity 52.5% (50.0% to 54.9%)). The modified HEART score increased the low-risk sensitivity to 98.4% (91.2% to 100.0%), with specificity 38.7% (36.3% to 41.1%). The 90-day incidence of AMI or death in the single rule-out and the original and modified low-risk HEART groups were 0.0%, 0.7%, and 0.2%, respectively.
CONCLUSION
In a primary care emergency setting, a single hs-cTnT strategy was superior to the HEART score in ruling out AMI. This rapid and safe approach may enhance the assessment of patients with chest pain outside of hospitals.
TRIAL REGISTRATION NUMBER
NCT02983123.
目的
本研究旨在比较在急性心肌梗死（AMI）低患病率的初级保健环境中，单次高敏肌钙蛋白 T（hs-cTnT）与病史、心电图、年龄、危险因素和肌钙蛋白（HEART）评分在排除 AMI 方面的安全性。
参与者
2016 年 11 月至 2018 年 10 月，挪威奥斯陆的一家初级保健急诊诊所连续招募了有非特异性 AMI 症状的患者。
方法
在全科医生初步评估后，抽取 hs-cTnT 样本。通过单次 hs-cTnT＜5ng/L 且测量时间距症状发作≥3 小时排除 AMI。使用回顾性计算 HEART 评分；得分≤3 分为 10 分中的低危。我们还使用更敏感的 hs-cTnT 阈值计算了改良的 HEART 评分。主要结局是在指数事件中排除 AMI 的诊断性能；次要结局是 90 天内 AMI 或全因死亡的复合结局。
结果
在 1711 例患者中，61 例（3.6%）诊断为 AMI，569 例（33.3%）患者采用单次排除（＜5ng/L）。该组中无 AMI 患者，阴性预测值（NPV）和敏感度均为 100.0%（95%CI 99.4%至 100.0%和 94.1%至 100.0%），特异性为 34.5%（32.2%至 36.8%）。原始 HEART 评分将更多患者分诊为低危（n=871），但漏诊了 5 例 AMI（NPV 99.4%（98.7%至 99.8%）；敏感度 91.8%（81.9%至 97.3%）和特异性 52.5%（50.0%至 54.9%））。改良 HEART 评分将低危敏感度提高至 98.4%（91.2%至 100.0%），特异性为 38.7%（36.3%至 41.1%）。在单次排除和原始及改良低危 HEART 组中，90 天 AMI 或死亡发生率分别为 0.0%、0.7%和 0.2%。
结论
在初级保健急诊环境中，单次 hs-cTnT 策略优于 HEART 评分，可排除 AMI。这种快速、安全的方法可能会增强对医院外胸痛患者的评估。
试验注册号
NCT02983123。
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