Institute of cardiovascular science, University College London, London, United Kingdom; Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom.
Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, United Kingdom.
Cardiovasc Revasc Med. 2022 Oct;43:13-17. doi: 10.1016/j.carrev.2022.04.003. Epub 2022 Apr 22.
Patients with aortic stenosis (AS) are susceptible to myocardial ischemia and often present acutely, making it challenging to differentiate between a type 1 NSTEMI and acute decompensated aortic stenosis. This study aims to evaluate the diagnostic accuracy of Troponin T (TnT) (>5 fold above the upper limit of normal), ischemic ECG and angina, to predict a type 1 non-ST elevation myocardial infarction (NSTEMI) and obstructive coronary artery disease (CAD) among patients with severe AS and acute presentations.
Patients with severe AS and acute symptoms: angina (Canadian Cardiovascular Society Class 3/4), dyspnea (New York Heart Association 4) and/or syncope were included. The endpoints were a type 1 NSTEMI defined by the presence of a coronary thrombus or > 90% stenosis and obstructive CAD defined as >70% stenosis, by computed tomography (CT) and/or invasive coronary angiography (ICA).
Out of 273 patients, 6.2% had a type 1 NSTEMI. Positive TnT, ischemic ECG and angina demonstrated negative predictive values of 95%, 94% and 97% respectively and positive predictive values of 12%, 9% and 13% respectively. Specificity increased with all three metrics (95%), whilst sensitivity and positive predictive value reduced (18% and 19% respectively). 39.2% of patients had obstructive CAD. Positive TnT, ischemic ECG and angina demonstrated sensitivity of 64%, 34% and 41% respectively and specificity of 57%, 77% and 77% respectively.
Angina, ischemic ECG and positive TnT are common among patients with AS presenting acutely and often not associated with a type 1 NSTEMI. These metrics, if positive, cannot reliably differentiate between a type 1 NSTEMI and acute decompensated AS. Coronary imaging using either CT or ICA is necessary to make a definitive diagnosis of a type 1 NSTEMI in patients with severe AS.
主动脉瓣狭窄（AS）患者易发生心肌缺血，且常表现为急性发作，因此区分 1 型非 ST 段抬高型心肌梗死（NSTEMI）与急性失代偿性主动脉瓣狭窄较为困难。本研究旨在评估肌钙蛋白 T（TnT）（>正常上限 5 倍）、缺血性心电图和心绞痛在预测严重 AS 伴急性表现患者发生 1 型 NSTEMI 和阻塞性冠状动脉疾病（CAD）方面的诊断准确性。
纳入严重 AS 伴急性症状（加拿大心血管学会分级 3/4 级心绞痛、纽约心脏协会 4 级呼吸困难和/或晕厥）的患者。终点事件为存在冠状动脉血栓或>90%狭窄的 1 型 NSTEMI 和>70%狭窄的阻塞性 CAD，通过计算机断层扫描（CT）和/或冠状动脉造影（ICA）进行定义。
在 273 例患者中，6.2%发生 1 型 NSTEMI。TnT、缺血性心电图和心绞痛阳性的阴性预测值分别为 95%、94%和 97%，阳性预测值分别为 12%、9%和 13%。所有三项指标的特异性均升高（95%），而敏感性和阳性预测值降低（分别为 18%和 19%）。39.2%的患者存在阻塞性 CAD。TnT、缺血性心电图和心绞痛阳性的敏感性分别为 64%、34%和 41%，特异性分别为 57%、77%和 77%。
急性发作的 AS 患者常出现心绞痛、缺血性心电图和 TnT 阳性，但通常与 1 型 NSTEMI 无关。如果这些指标阳性，不能可靠地区分 1 型 NSTEMI 与急性失代偿性 AS。对于严重 AS 患者，需要使用 CT 或 ICA 进行冠状动脉成像以明确诊断 1 型 NSTEMI。
