D-二聚体对 ST 段抬高型心肌梗死患者主动脉夹层的筛查作用。

D-dimer for screening of aortic dissection in patients with ST-elevation myocardial infarction.

机构信息

Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan.

出版信息

Am J Emerg Med. 2022 Sep;59:146-151. doi: 10.1016/j.ajem.2022.07.024. Epub 2022 Jul 16.

DOI:10.1016/j.ajem.2022.07.024

PMID:35868207

Abstract

BACKGROUND

Acute aortic dissection (AAD) with concurrent ST-segment elevation myocardial infarction (STEMI) is relatively rare and sometimes overlooked. As D-dimer testing has been reported to have high sensitivity to diagnose AAD in a clinical scale, Aortic Dissection Detection Risk Score (ADD-RS), a point-of-care D-dimer analyzer capable of measuring in 10 min would be useful to deny AAD with concurrent STEMI. However, an optimal cut-off value of D-dimer in such population remains unclear. Therefore, the aim of this study was to elucidate the optimal D-dimer threshold in patients clinically diagnosed with STEMI.

METHODS

This retrospective cohort study was conducted at two tertiary care centers between 2014 and 2019. Patients clinically diagnosed with STEMI who underwent serum D-dimer measurement on hospital arrival were included. The primary outcome was the diagnosis of AAD. The area under the receiver operating characteristic curve (AUROC) for D-dimer values to diagnose AAD was evaluated, particularly in patients with low to moderate risks of AAD (1 of ADD-RS). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated with several cut-off values.

RESULTS

A total of 322 patients were included, and 28 were diagnosed with AAD. The AUROC for D-dimer to diagnose AAD was 0.970 (95% confidence interval: 0.948-0.993) in 262 patients with 1 of ADD-RS. If D-dimer ≥750 ng/mL was used as a cut-off value, sensitivity, specificity, PPV and NPV were 100%, 86.4%, 37.7%, and 100%, respectively. AAD could be denied in 209 (79.8%) patients using the cut-off value (D-dimer <750 ng/mL).

CONCLUSIONS

Serum D-dimer ≥750 ng/mL exhibited high sensitivity and NPV to diagnose AAD with concurrent STEMI, while the ADD-RS originally utilized ≥500 ng/mL as a cut-off for any suspected AAD. A point-of-care D-dimer measurement with the new cut-off would be useful to rule-out AAD among patients with STEMI.

摘要

背景

急性主动脉夹层（AAD）并发 ST 段抬高型心肌梗死（STEMI）相对少见，有时容易被忽视。由于 D-二聚体检测在临床上诊断 AAD 具有较高的灵敏度，因此一种能够在 10 分钟内测量的即时检测 D-二聚体分析仪——Aortic Dissection Detection Risk Score（ADD-RS），可能有助于排除并发 STEMI 的 AAD。然而，在这种人群中，D-二聚体的最佳截断值尚不清楚。因此，本研究旨在确定临床上诊断为 STEMI 的患者中 D-二聚体的最佳截断值。

方法

这是一项在 2014 年至 2019 年期间在两家三级护理中心进行的回顾性队列研究。纳入了在入院时接受血清 D-二聚体检测的临床上诊断为 STEMI 的患者。主要结局是 AAD 的诊断。评估了 D-二聚体值诊断 AAD 的受试者工作特征曲线（AUROC），特别是在 ADD-RS 评分低至中度的患者中（1 分）。计算了几个截断值的敏感性、特异性、阳性预测值（PPV）和阴性预测值（NPV）。

结果

共纳入 322 例患者，其中 28 例诊断为 AAD。在 262 例 ADD-RS 评分 1 分的患者中，D-二聚体诊断 AAD 的 AUROC 为 0.970（95%置信区间：0.948-0.993）。如果将 D-二聚体≥750ng/ml 作为截断值，敏感性、特异性、PPV 和 NPV 分别为 100%、86.4%、37.7%和 100%。使用截断值（D-二聚体＜750ng/ml）可以排除 209 例（79.8%）患者的 AAD。