From the Heart and Vascular Institute, Henry Ford Health System, Detroit, MI.
Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI.
Crit Pathw Cardiol. 2021 Sep 1;20(3):134-139. doi: 10.1097/HPC.0000000000000262.
Although the recommended cut point for cardiac troponin (cTn) is the 99th percentile, many institutions use cut points that are multiples higher than the 99th percentile for diagnosing acute myocardial infarction (AMI). Prior studies have shown that patients with a HEART score (HS) ≤ 3 and normal serial cTn values (modified HS) are at low risk for adverse events. This study aimed to evaluate the prognostic utility of the HS when various cTn cut points are used.
This was a substudy of High Sensitivity Cardiac Troponin T assay for RAPID Rule-out of Acute Myocardial Infarction (TRAPID-AMI), a multicenter, international trial evaluating a rapid rule-out AMI study using high-sensitivity cardiac troponin T (hs-cTnT). One-thousand two-hundred eighty-two patients were evaluated for AMI from 12 centers in Europe, United States, and Australia from 2011 to 2013. Blood samples of hs-cTnT were collected at presentation and 2 hours, and each patient had a HS calculated. The US Food and Drug Administration approved 99th percentile for hs-cTnT (19 ng/L) was used.
There were 213 (17%) AMIs. Within 30 days, there were an additional 2 AMIs and 8 deaths. The adverse event rates at 30 days (death/AMI) for a HS ≤ 3 and nonelevated hs-cTnT over 2 hours using increasing hs-cTnT cut points ranged from 0.6% to 5.1%.
Using the recommended 99th percentile cut point for hs-cTnT, the combination of a HS ≤ 3 with nonelevated hs-cTnT values over 2 hours identifies a low-risk cohort who can be considered for discharge from the emergency department without further testing. The prognostic utility of this strategy is greatly lessened as higher hs-cTnT cut points are used.
虽然推荐的心脏肌钙蛋白（cTn）截断值为第 99 百分位，但许多机构使用的截断值比第 99 百分位高出许多，用于诊断急性心肌梗死（AMI）。先前的研究表明，心脏评分（HS）≤3 且连续检测心脏肌钙蛋白值正常（改良 HS）的患者发生不良事件的风险较低。本研究旨在评估当使用不同心脏肌钙蛋白截断值时 HS 的预后价值。
这是一项高敏心肌肌钙蛋白 T 用于快速排除急性心肌梗死的研究（TRAPID-AMI）的子研究，该研究是一项多中心、国际试验，评估了使用高敏心肌肌钙蛋白 T（hs-cTnT）的快速排除急性心肌梗死的研究。2011 年至 2013 年，来自欧洲、美国和澳大利亚的 12 个中心共评估了 1282 例疑似 AMI 的患者。在就诊时和 2 小时时采集 hs-cTnT 血样，并计算每位患者的 HS。美国食品和药物管理局批准的 hs-cTnT（19ng/L）第 99 百分位用作截断值。
共有 213 例（17%）AMI。在 30 天内，又发生了 2 例 AMI 和 8 例死亡。在 30 天内（死亡/AMI），使用逐渐升高的 hs-cTnT 截断值，当 HS≤3 且 2 小时 hs-cTnT 值不升高时，不良事件发生率（死亡/AMI）范围为 0.6%至 5.1%。
使用 hs-cTnT 的推荐第 99 百分位截断值，当 HS≤3 且 2 小时 hs-cTnT 值不升高时，联合使用可以识别出低风险患者，可以考虑从急诊科出院，无需进一步检查。随着使用更高的 hs-cTnT 截断值，这种策略的预后价值大大降低。
