Kavsak Peter A, Mondoux Shawn E, Hewitt Mark K, Ainsworth Craig, Hill Stephen, Worster Andrew
Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada.
Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada.
J Cardiovasc Dev Dis. 2021 Sep 1;8(9):106. doi: 10.3390/jcdd8090106.
Guidelines published in 2021 have supported natriuretic peptide (NP) testing for the prognostication in patients with acute coronary syndrome (ACS) and for the diagnosis of chronic and acute heart failure (HF). Our objective was to determine if the addition of N-terminal pro B-type NP (NT-proBNP) and glucose to high-sensitivity cardiac troponin (hs-cTn) could better identify emergency department (ED) patients with potential ACS at low- and high-risk for a serious cardiovascular outcome over the next 72 h. The presentation sample in two different ED cohorts which enrolled patients with symptoms suggestive of ACS within six hours of pain onset (Cohort-1, = 126 and Cohort-2, = 143) that had Abbott hs-cTnI, Roche hs-cTnT, NT-proBNP and glucose were evaluated for NT-proBNP alone and combined with hs-cTn and glucose for the primary outcome (composite which included death, myocardial infarction, HF, serious arrhythmia and refractory angina) via receiver-operating characteristic (ROC) curve analyses with area under the curve (AUC) and diagnostic estimates derived. The AUC for NT-proBNP for the primary outcome was 0.68 (95% confidence interval (CI): 0.59-0.76) and 0.75 (95%CI: 0.67-0.82) in Cohort-1 and 2, respectively, with the 125 ng/L cutoff yielding a higher sensitivity (≥75%) as compared to the 300 ng/L cutoff (≥58%). Using the 125 ng/L cutoff for NT-proBNP with the published glucose and hs-cTn cutoffs for risk-stratification produced a new score (GuIDER score for Glucose, Injury and Dysfunction in the Emergency-setting for cardiovascular-Risk) and yielded higher AUCs as compared to NT-proBNP ( < 0.05). GuIDER scores of 0 and 5 using either hs-cTnI/T yielded sensitivity estimates of 100% and specificity estimates > 92% for the primary outcome. A secondary analysis assessing MI alone in the overall population (combined Cohorts 1 and 2) also achieved 100% sensitivity for MI with a GuIDER cutoff ≥ 2, ruling-out 48% (Roche) and 38% (Abbott) of the population at presentation for MI. Additional studies are needed for the GuIDER score in both the acute and ambulatory setting to further refine the utility, however, the preliminary findings reported here may present a pathway forward for inclusion of NP testing for ruling-out serious cardiac events and MI in the emergency setting.
2021年发布的指南支持使用利钠肽（NP）检测对急性冠状动脉综合征（ACS）患者进行预后评估以及对慢性和急性心力衰竭（HF）进行诊断。我们的目的是确定在高敏心肌肌钙蛋白（hs-cTn）基础上增加N末端B型利钠肽原（NT-proBNP）和葡萄糖是否能更好地识别急诊科（ED）中在未来72小时内有严重心血管不良结局低风险和高风险的潜在ACS患者。在两个不同的ED队列中，纳入疼痛发作6小时内有ACS症状的患者（队列1，n = 126；队列2，n = 143），检测了雅培hs-cTnI、罗氏hs-cTnT、NT-proBNP和葡萄糖，通过受试者操作特征（ROC）曲线分析及曲线下面积（AUC）和诊断估计值，单独评估NT-proBNP以及将其与hs-cTn和葡萄糖联合用于主要结局（包括死亡、心肌梗死、HF、严重心律失常和难治性心绞痛的复合结局）。队列1和队列2中NT-proBNP对主要结局的AUC分别为0.68（95%置信区间（CI）：0.59 - 0.76）和0.75（95%CI：0.67 - 0.82），与300 ng/L的临界值（≥58%）相比，125 ng/L的临界值产生更高的敏感性（≥75%）。将NT-proBNP的125 ng/L临界值与已公布的用于风险分层的葡萄糖和hs-cTn临界值相结合产生了一个新的评分（急诊环境下心血管风险的葡萄糖、损伤和功能障碍的GuIDER评分），与NT-proBNP相比，其AUC更高（P < 0.05）。使用hs-cTnI/T时，GuIDER评分为0和5对主要结局的敏感性估计为100%，特异性估计> 92%。在总体人群（队列1和队列2合并）中单独评估心肌梗死的二次分析中，GuIDER临界值≥2时对心肌梗死的敏感性也达到100%，在就诊时排除了48%（罗氏）和38%（雅培）的心肌梗死人群。在急性和门诊环境中对GuIDER评分还需要进行更多研究以进一步完善其效用，然而，此处报告的初步结果可能为在急诊环境中纳入NP检测以排除严重心脏事件和心肌梗死提供了一条前进的途径。
